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NYC Health + Hospitals Will Create Best Practice "Playbook" to Identify and Engage High-Risk, High-Need Patients

$209K Grant from Commonwealth Fund Will Support Qualitative Data Collection and Identify Innovative Strategies to Improve Care for Patients Who Are Frequent Users of High-Acuity Services

Nov 13, 2018

New York, NY

NYC Health + Hospitals was awarded a $209,000 grant from the Commonwealth Fund to more effectively deliver complex care to high-need patients and to tap the public health system’s expertise and experience in creating and disseminating guidelines for best practices on managing high-risk populations for other safety-net systems.

The grant will fund the sharing of best practices within Health + Hospitals and support development of a new guiding document “Complex Care Implementation Guide for Safety-Net Health Systems”—a playbook to help others develop their own programs to improve care coordination for high-need patients.

“This generous grant will enable us to take what we learn and package it to benefit all safety-net health systems,” said Dave A. Chokshi, MD, MSc, FACP, Vice President and Chief Population Health Officer at NYC Health +Hospitals. “We expect that this will result in better health outcomes and more coordinated, less fragmented, seamless care for all patients across the board. We are grateful to the Commonwealth Fund for supporting this important work.”

“The Commonwealth Fund is pleased to partner with Health + Hospitals to spread effective practices among safety-net health systems around the country to improve care for our most complex and vulnerable patients,” said Tanya Shah, Assistant Vice President for Delivery System Reform at the Commonwealth Fund. “This work will aim to help create a high-performance health system that provides better care and health outcomes for everyone.”

The Commonwealth Fund grant will support three specific components of the project:

  • Completion of clinical workshops designed to elicit insights and qualitative feedback on the different needs and behaviors of high-risk patients at NYC Health + Hospitals. The information generated will help identify distinct patient profiles, which will be used to inform the development of pilot interventions for high-risk patients;
  • Implementation of novel care models for high-risk, high-need patients. Based on results of the clinical workshops, NYC Health + Hospitals will launch approximately three projects designed to address the needs and behaviors of a specific subgroup of high-risk patients, e.g., enhanced care coordination for high-risk patients with comorbid medical, social, and behavioral conditions who are disengaged from primary care and;
  • Dissemination of lessons learned and best practice guidelines. NYC Health + Hospitals will develop and refine a playbook, which will include practical resources for frontline staff. This will involve enlisting a group of other safety-net providers who will review and provide feedback on the playbook. Lessons learned and best practices will be published by NYC Health + Hospitals in open-access outlets, through the Commonwealth Fund and other partner resources.

America’s Essential Hospitals—and its AEH Institute—will serve as a collaborating partner on the project, which includes supporting NYC Health + Hospitals’ efforts to engage diverse advisors, as well as expand the reach of practical resources to other safety-net systems.

NYC Health + Hospitals is widely recognized for its leadership in value-based care efforts, which include:

  • The health system’s Accountable Care Organization—a group of doctors and other providers who coordinate care for patients under the Medicare Shared Savings Program—for the fifth consecutive year achieved savings and outstanding quality performance. Keys to performance included improving care coordination in the primary care setting and preventing unnecessary emergency department visits, avoidable hospitalizations, and other high-cost care for the more than 10,000 Medicare fee-for-service patients who are served through the program.
  • OneCity Health is the NYC Health + Hospitals-sponsored Performing Provider System under the State’s Delivery System Reform Incentive Payment program, designed to reduce avoidable and unnecessary hospital stays. As the largest Performing Provider System in New York City, OneCity Health comprises hundreds of health care providers and community-based organizations who work together to keep communities healthy.

“NYC Heath + Hospital’s experience in managing high-risk patients makes us the perfect partner in this endeavor, and we look forward to coordinating with America’s Essential Hospitals and the Commonwealth Fund with the ultimate goal of improving care for all of the underserved,” said Dr. Chokshi. “We’ve proven that value-based care can succeed in the largest public health care system in the country and look forward to continuing to improve the health of our most vulnerable patients.”