BPHC kicked off the overall implementation of the DSRIP initiative on December 3rd, and will also host individual launch events for all ten projects. The Health Home At-Risk Intervention Program will be the next project to get off the ground, with its launch event to be held the week of January 11th.
The Health Home At-Risk project will provide an early intervention program for Bronx residents who suffer from one chronic illness, but whose health is rapidly declining and, if left unchecked, is likely to require Health Home and hospital services in the future. Care coordinators embedded within primary care teams will identify these at-risk patients based on both medical and social determinants of health. They will then connect patients to the right healthcare services to manage medical issues and to the right community-based organizations to build a healthier lifestyle, before their health gets any worse.
Care coordinators will manage each patient’s care plan in a Care Coordination Management System (CCMS). Providers may use a variety of CCMS platforms, but this project will standardize a set of core data elements describing patients, making it possible to aggregate patient information from multiple providers. Click Here to learn more about Health Home At-Risk and other BPHC projects.