New care model that includes longer visits aims to reach patients before they need emergency or hospital services

Medicaid patients have mounting care needs, poorly managed chronic conditions and often socioeconomic barriers that keep them from preventive care. The ambulatory care department at Jamaica Hospital Medical Center, a safety-net hospital serving an under-resourced, heavily Medicaid population in Queens, New York, introduced a new care delivery model to reach these patients earlier. First, they used a third-party vendor to incorporate a risk-scoring tool to find patients at the highest risk of needing hospital or emergency care. A team of clinicians, case managers, navigators, behavioral health staff, and social workers chose who to prioritize, then planned and debriefed the visits. Those patients received 40-minute high-value visits, more than twice the 18-minute average for primary care. Physicians and residents were trained to look past the diagnosis to what gives patients’ lives meaning and to behavioral and environmental factors that may affect their health. Patient navigators, hired with state funding through a Medicaid demonstration waiver, handled outreach, prescriptions, lab work and referrals and identified barriers such as transportation and housing. The model led to reduced care use, improved chronic disease management, and lower costs within the Medicaid managed population.

A Novel Care Model for Managing the Rising-Risk Medicaid Population in a Safety-Net Hospital

Corresponding Author: Alan Roth, DO, FAAFP, et al

Jamaica Hospital Medical Center, Jamaica, New York

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