Some of New York's most vulnerable patients present both the highest needs and the highest costs to the health care system. Lack of coordination or communication among providers causes many of these patients to fall through the cracks. Recent efforts have sought to break down traditional silos and provide patients with a seamless spectrum of services that meet the entirety of their needs. For these efforts to succeed, payment systems must change to create the proper incentives for care integration and to discourage unnecessary and costly utilization such as hospitalizations or emergency room (ER) visits. In 2013, NYSHealth awarded Maimonides Medical Center a grant to develop an all-encompassing total-cost-of-care reimbursement model to improve the delivery and financing of care for patients with serious mental illness. Under this grant, Maimonides planned to assess the costs and benefits of social services and to incorporate them into a comprehensive total cost of care model. Shortly after the grant was awarded, New York State adopted Health and Recovery Plans (HARPs), which defined benefit packages for patients with serious mental illness and in many ways addressed the gaps that Maimonides' project aimed to resolve. In 2014, Maimonides redesigned its project to focus on (1) identifying social services that have the most positive results on patients' health care utilization and outcomes through claims data and (2) determining how savings achieved through reductions in medical expenditures can be reinvested in developing a scalable and sustainable social services infrastructure in Brooklyn.
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