Health Home At Risk

Project 2.a.iii

Health Home at Risk Intervention Program



According to our Community Needs Assessment (CNA), the MHVC region has two important gaps in patient care: (1) Insufficient care management and integration resources, and (2) lack of availability of providers and community resources. The CNA also revealed that approximately 10% of the Hudson Valley population are high utilizers of health care, and another 25% are at risk of entering this high-utilization category if they do not receive appropriate interventions. These individuals often have complex medical, behavioral, and social needs that are difficult to coordinate and can complicate their care.

The Health Home At-Risk project is designed to engage patients with complex needs who are not currently enrolled in, or may not be eligible for, services under the New York State Department of Health (NYS DOH) Health Home program. Under this MHVC project, primary care patients will receive team-based care including care coordination, care planning, and self-care supports through the Patient-Centered Medical Home (PCMH) practice. PCMH is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.

Provider teams will collaborate with patients to develop patient-centered care plans that address patient priorities including the social determinants of health, provide evidence-based treatment that empowers self-management, and includes meaningful connections and coordination with other healthcare and social service providers.


This project focuses on developing a patient-centered, comprehensive, and coordinated system of care in primary care settings. Our goal is to provide these members with active outreach and care management to address their physical and behavioral needs and the social determinants of their health, including:

  • Increasing referrals to Health Homes, and
  • Care managers, who can help this vulnerable population navigate the health care system and reduce ED and inpatient utilization while increasing use of community based organization/resources.


3 Executive Boulevard
3rd Floor
Yonkers NY 10701

E-mail montefiorehvc@montefiore.org
Website www.montefiorehvc.org