Dr. Martin Luther King, Jr. Health Center

Patients with repetitive hospitalizations frequently suffer from comorbid conditions including psychiatric illness, substance use issues, and multiple chronic illnesses.

In the Bronx, these patients also face challenges related to poverty, illiteracy, housing instability, and abusive relationships. These high-need patients account for almost 80% of Medicaid spending. The Dr. Martin Luther King, Jr. Health Center (MLK), together with the Bronx-Lebanon Hospital Center, implemented an Intensive Wellness Program, which shifted high-cost inpatient services into comprehensive primary care to lower costs and improve health outcomes.

The Intensive Wellness Program focused on Medicaid patients who are hospitalized regularly and suffer from co-morbid medical and psychiatric illness by addressing health, addiction, social, and mental needs. The program is an integrated, multidisciplinary primary care-based service that includes general and mental health care, community outreach, and intensive case management. Using a tool developed specifically to identify high utilizing patients, the program identified 250 Medicaid patients who are at great risk for re-hospitalization.

MLK ultimately adapted the program as a therapeutic model for patients with complex and chronic needs across their primary care setting, which serves 3,000 patients. This project trained the providers in using this application for treating high-cost and high-need patients. In addition to implementing the Intensive Wellness Program, MLK evaluated the cost effectiveness and patient outcomes related to this intervention. MLK expected to reduce utilization by 20% through decreased hospital admissions.