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.

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

NYU Langone adult patients (>18 years old) at or above the 75th percentile on NYU's mortality model currently attributed to one of DSRIP's value based contracts.