Morality, Patient Engagement
Conditions
Brief summary
NYU's High Risk Program targets patients who may be more likely to have increased hospitalization due to health conditions that may cause death in the near future. Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.
Interventions
BEHAVIORALSupportive care program
Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.
Sponsors
NYU Langone Health
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Inclusion criteria
* 18 years or older * at or above the 75th percentile on the Mortality Model * Attributed to a value based contract
Exclusion criteria
* Less than 18 years of age * Below the 75th percentile on the Mortality Model * Not attributed to a value based contract
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Rate of Advance Care Planning note creation | 2 years | How many and how often are ACP notes written for patients |
Countries
United States
Outcome results
None listed