Expanding Health Care Coverage

Project Title

Improving Care and Reducing Hospital Admissions and Costs for Patients at High Risk of Frequent Hospital Admissions

Grant Amount


Priority Area

Expanding Health Care Coverage

Date Awarded

May 26, 2009








Patients with frequent hospital admissions comprise a small number of overall patients, but account for a disproportionate share of hospital visits and costs.

Twenty percent of Medicaid patients account for almost 80% of Medicaid expenditures in New York State. In order to reduce the cost of health care in New York State, the Medicaid system needs programs that better address patients’ needs and deliver more cost-effective care.

An analysis of Bellevue Hospital Center’s (Bellevue) patient population showed that high users of inpatient services share many risk factors for hospitalization including homelessness, social isolation, substance abuse, depression, and anxiety. Now, Bellevue identifies whether a patient is at high-risk of another hospitalization when he or she initially arrives. Once identified as high-risk, a case manager is assigned to monitor and coordinate the services a given patient requires. The case manager continues to be involved in the patient’s care until after he or she is discharged, ultimately providing invaluable service to this high-risk population as they navigate the complex world of medical services. Bellevue collaborates with a variety of community-based organizations to assist the patients with their diverse needs.