Implementing a Health and Mental Health Intervention for High-Cost Patients

A relatively small proportion of Medicaid patients account for a disproportionate share of health care utilization and costs.

This patient population often churns through hospitals and emergency rooms (ERs) and suffers from co-morbid conditions, such as mental illness, substance use, and other chronic conditions for which care is limited. For such patients, the solution may not solely lie in medical treatments but in a program that addresses the myriad medical, social, mental health, and substance use issues they face.

In May 2008, the New York Health Foundation awarded a grant to the Dr. Martin Luther King Jr. Health Center (MLK Health Center), a federally qualified health center affiliated with Bronx-Lebanon Hospital Center, to launch the Intensive Wellness Program (IWP). Based at the MLK Health Center in the Bronx, IWP is an integrated primary care treatment and patient engagement program that includes medical and mental health services, community outreach, communication across multidisciplinary teams, and intensive care management for complex patients with multiple chronic illnesses.