Complex Care at NYC H+H: Operational Guide to Identify, Understand, and Treat High-Need Patients

Resource Location:

NYC Health & Hospitals

This guide features open-source implementation tools which could be customized, and used to support other health system’s efforts to identify, understand, and treat patients with complex needs.
This guide provides step-by-step guidance on:
1) Risk scoring and stratification: using data and analytics to identify patients with complex needs;
2) Segmentation: combining analytics with clinical insight to understand patients with complex needs; and
3) Targeting: tailoring care models to fit needs and behaviors of patients with complex needs.

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Focus Area: Health Equity, Readmissions / Care Transitions