By Melinda Young


When a five-year, federally funded demonstration project began in New York, the goals were lofty: reduce preventable readmissions by 25% or more. NYU Langone Health achieved this goal through identifying frequent users and working with them through a targeted case management approach.

• The first step was determining barriers to health compliance.

• Next, the program integrated behavioral health into clinical care settings.

• The process also included an outreach team that contacts frequent users by phone or at their homes.

A national Medicare demonstration project resulted in dramatic reductions of avoidable admissions in the ED of a New York City hospital. The program used a case management approach for frequent users.

“We’re a high-volume Medicaid provider,” says Larry K. McReynolds, executive director of Family Health Centers at NYU Langone in Brooklyn.

The health system was part of Delivery System Reform Incentive Payment (DSRIP), which is a five-year, federally funded demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS) and administered by the New York State Department of Health. It ends in 2020. The chief DSRIP goal was for health systems to reduce avoidable hospital use by 25% between July 1, 2014, and June 30, 2019. (More information on the project is available at:

According to the DSRIP performance dashboard available only to the New York performing provider systems (PPS), NYU Langone is one of two New York systems that already has achieved the statewide goals of reducing potentially preventable readmissions by 25% or more, says Kris Batchoo, assistant director of DSRIP operations and reporting at NYU Langone Health. “We were the best performer in the state for that measure,” Batchoo adds. The health system also reduced ED visits by greater than 25%, he adds.

The New York State Department of Health still was evaluating data from the 25 systems participating in DSRIP through late August, and was unable to provide unpublished comparison evaluation information to Hospital Case Management, according to an email from Jeffrey Hammond, public information officer.

With an estimated 120,000 Medicaid patients, the health system first conducted a community needs assessment and found that its chief focus areas were diabetes, asthma, HIV care, behavioral health, and smoking cessation. The NYU Langone Brooklyn Performing Provider System includes the Family Health Centers at NYU Langone and more than 200 primary care providers, mental health centers, and other providers. “We built those projects into our DSRIP program,” Batchoo says.

Soon, NYU Langone developed a patient navigation center and focused on identifying frequent users, the people who returned repeatedly to the ED within the previous 12 months, Batchoo says.

With greater focus on case management of that population, the theory was that the frequent users could be kept healthier and out of the hospital. “Once we knew who our high-utilizer patients were, we identified their barriers to health compliance and provided them with more targeted case management,” McReynolds says.

Case managers helped identify their transportation needs and other barriers to outpatient appointments, he says.

They learned, as many case managers have, that targeting patients placed in groups according to their disease or health issue does not work as efficiently as looking at frequent users through the filter of a holistic health perspective.

“In the past, a lot of projects we worked on involved dealing with patients in a clinical category, and that was too limiting,” McReynolds says. “What we found in looking at people who were high utilizers was that it was diabetes with depression, whereas in the past we looked just at diabetics or just at depressed patients.”

Seeing patients according to their behavior, such as frequent use of the ED, helped the medical team to see a patient as a whole person with multiple chronic disease issues, he adds.

“This led us to integrating behavioral health into clinical care settings,” McReynolds says. “Previous to DSRIP, all behavioral health was done at one large clinic; now, behavioral health professionals are in all clinic sites and the hospital.”

New York was leading the way with a federal waiver and redesign of the Medicaid program in an effort to move away from fee-for-service to value-based reimbursement. As part of this effort, the state mandated a behavioral health project, Batchoo explains. “That was an area the state wanted to focus on, and we have a behavioral health work group,” he says. “We work with partners across the spectrum to identify behavioral health needs and to put processes in place to move the needle on district performance measures.”

The processes included an outreach team. Community health workers contact frequent patients via phone or in person. Their goal is to engage with patients and learn more about their underlying issues, including social determinants of health, Batchoo explains.

Community health workers then share what they learned with case managers and other professionals, who work to overcome those access and health barriers.

Often, the most pressing need among these patients is housing, McReynolds says. “Or maybe they don’t have enough food for the next two days,” he adds. “We found out that addressing just their clinical needs often doesn’t work if the patient feels there is a more pressing need that is more important to them.”

The case management goal is to address patients’ needs holistically. “We find out what are the patient’s needs and what does the patient see as a priority,” McReynolds explains. Making this change has resulted in a greater percentage of patients keeping their doctors’ appointments, he adds.

Case managers also contact community-based organizations to find resources for patients. They connect patients with primary care physicians and federally qualified health centers with sliding income scales that make patients’ primary care affordable, he says.

If a patient qualifies for food stamps, case managers could see if the patient also qualifies for housing, medication assistance, or other social programs, McReynolds says. “We can make it as easy as possible for people to get all of the subsidies they are eligible for, and that builds trust with patients,” he notes.

One of the common refrains the health team heard from patients was that they were assessed and then got a referral, which meant they had to travel to yet another office, and good luck with that, McReynolds recalls. The new case management approach means closing the loop. Case managers and social workers help connect patients with an agency and stay with them through the application process until they receive the resources they need, McReynolds says.

“We even give them food from our food pantry if they are that much at risk,” he adds. “People need food, transportation, a doctor, and not just a name and number to call.”

Walking patients through the referral process and putting them directly in touch with services and primary care providers has made all the difference in the program’s positive outcomes, Batchoo notes.

“To achieve a 25% reduction in avoidable hospital use, you have to engage patients and providers and make sure you have the right strategy,” he says.

McReynolds had experience with running a federally qualified health center, and he knew a key component of success in reducing admissions is to identify the sicker patients and get them quicker access to healthcare.

“We made sure any high utilizer received a needed appointment within seven days. If they needed an appointment the next day, we would help them get it,” McReynolds says. “We made our schedule more flexible to get them in, and it worked great, helping us get bonuses for improving our quality,” he adds. “It’s dramatically improved the quality from the plan’s perspective, which eventually will help us do a shared-savings model in the future.”