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2.a.iii: Health Home At-Risk Intervention Program

Proactive Management of Higher Risk Patients Not Currently Eligible for Health Homes through Access to High Quality Primary Care and Support Services

Project Objective: This project will expand access to community primary care services and develop integrated care teams (physicians and other practitioners, behavioral health providers, pharmacists, nurse educators and care managers from Health Homes) to meet the individual needs of higher risk patients. These patients do not qualify for care management services from Health Homes under current NYS HH standards (i.e., patients with a single chronic condition but are at risk for developing another), but on a trajectory of decreasing health and increasing need that will likely make them HH eligible in the near future.

Project Description: There is a population of Medicaid members who do not meet criteria for Health Homes but who are on a trajectory that will result in them becoming Health Home super-utilizers. This project represents the level of service delivery and integration for the complex super-utilizer population who fall in between the patient-centered medical home and the Health Home general population. Some risk stratification systems refer to these patients as “the movers.” Early intervention through this project shall result in stabilization reduction in health risk and avoidable service utilization.


PMO Suehane Sanchez
Community Co-Lead: 
Stephen Williams, BrightPoint Health 
BLHC Co-Lead: 
David Ferris, MD & Maribel Montanez, RN

Nov 13, 2017

Project Updates – Fall 2017

As of DY2Q4, the Health Home at Risk project has completed 71% of project milestones. 

DY3 welcomed a number of new contracted partners to the Health Home at Risk project.  In order to locate patients with “rising risk” (1 chronic condition and at risk for development of a 2nd condition), the project has implemented a model where embedded care coordinators will identify, engage, enroll, and support patients in meeting health outcomes, as identified by their primary care team. 

We look forward to sharing further outcomes of this vital work in population management and are proud to partner with the following agencies in our network:

-          Boom! Health

-          Brightpoint Health

-          Bronx Lebanon Hospital Center

-          Dennelisse Corporation

-          Hudson Heights IPA

-          Unique People Services

-          Urban Health Plan

-          VIP Community Services


A vendor agreement with expectations for targeted patient caseload/care coordination services has been signed. Ongoing monthly meetings are held with our 7 partners to share best practices.


Collaboration with BHA Cardiology department has allowed us to embed a CHW as of July.


An “Action list” in the Electronic Medical Record (EMR) at BLHC was implemented to identify eligible patients for HH@R.  This will enable CHWs and care team members to proactively outreach to eligible patients.

Sep 30, 2016

Project Update for September 2016

Nicole Bernier has been hired as the new Program Manager for HH@R. Nicole has a strong background in Social Work and was most recently a key staff member in the Bronx Health Home. Ms. Bernier is in the process of being oriented to the Project. An Administrative Assistant candidate has also been identified and is in the process of being interviewed/vetted.

HH@R continues to identify potential partners for inclusion in the project. Preliminary discussions to assess fit include a review of Health Home At Risk project guidelines and documentation requirements. Final discussions involve a vendor agreement with expectations for targeted patient caseload/care coordination services.

The Care Coordination community of Bronx Health Access has been invited to a lecture on 9/29/16 by Dr. Sherya Kangovi, University of Pennsylvania, who will be speaking about the IMPaCT model (Individualized Management towards Patient Centered-Targets). The IMPaCT incorporates patient perspectives on the socioeconomic determinants of their health and healthcare utilization and the effectiveness of the Community Health Worker in modifying these determinants.

Aug 31, 2016

Project Update for August 2016

Recruitment/hiring of key staff continues for the Health Home At Risk project. The team is looking to add a Program Manager and an Administrative Assistant. The team is also continuing to engage partners under the “Hybrid Model” of Care Coordination.

A “booster training” was conducted in late July by Bronx Health Home staff for all Participating Partners who have hired Care Coordinators. The training highlighted the documentation process (Care Assessment/Care Plan) and entry into Care Director. Plans continue for an upcoming, in-depth training in Chronic Disease management and Care Coordination skills-building (by Cicatelli Associates). As well, a clinical subject matter expert in Care Coordination has been invited to speak to Participating Partners in the HHAR Project. Dr. Shreya Kangovi, from the University of Pennsylvania, is scheduled to speak on 9/29th on the IMPaCT Care Coordination model. She will first address morning Medical Grand Rounds with Primary Care/Health Home clinicians, to be followed by a lecture for ~80 persons from Care Coordination leadership. In addition, Dr. Kangovi is scheduled to address the Care Coordination staff currently servicing the HHAR Project.

Jul 31, 2016

Project Update for July 2016

An alternate site has been located for the Bronx-Lebanon Care Coordinators (known as “Community Health Educators”) along with the Program Manager and Administrative Assistant. This site will also house the “Clearinghouse” team which will support connection and handoffs between Health Homes and Primary Care Providers.

An in-person training was conducted by Bronx Health Home staff for all Participating Partners who have hired Care Coordinators. The training included a review of the HHAR Project criteria; an Introduction to Care Director, the care management database, and the documentation process (Care Assessment/Care Plan). Plans are still being developed for a future, in-depth training in Chronic Disease management and Care Coordination skills-building with an outside training vendor.

BLHC continues its participation on the GNYHA Care Plan Content Subgroup and also participates in a city-wide collaborative of other PPS’s addressing the Health Home At Risk Project.