Treating the Whole Person

The Niagara Falls Memorial Medical Center (NFMMC) Health Home is a Medicaid-funded coordinated care management program that provides services to at-risk adults and children in Niagara County, NY. The health home focuses on delivering an integrated and coordinated experience across the continuum of care, including among its services comprehensive care management, post-hospitalization follow-up, and working with community and social services to provide the additional support patients need to improve their health.

NFMMC uses Aerial™ Health Coordinator to document and manage all care coordination activities for health home members, including activities that take place at the hospital and with downstream providers.

Success Story

Reduced readmissions by 66%
Cost savings of $98K year-over-year for top 22 utilizers

The Challenge: Holistic Care for At-Risk Patients to Minimize Risk

NFMMC Health Home clients have high needs—eligibility requires a serious mental health diagnosis or a minimum of two qualifying chronic conditions, and many are homeless or displaced in the community. “As a health home in a poor, rural community, our clients often have more at-risk problems than seen at other health homes,” said Tiffany Cook, Director of the Adult and Children Health Home at NFMMC. “We focus on getting them the right level of care and keeping them out of the ED.”

For these patients, complex and overlapping social, economic, environmental, and societal issues can interfere with treatment plans and exacerbate chronic diseases. Treating the whole person by addressing behavioral and social determinants of health (SDOH) in addition to medical care not only helps this vulnerable population deal with all their issues so that they can become healthier, but also reduces the risk of high-cost emergency treatment.

Tiffany Cook

“Without our health home, many of our clients would fall through the cracks,” said Cook. “Our care managers do a phenomenal job of keeping their fingers on the pulse of their social needs as well as their health needs.”

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Success Story

Treating the whole person helps reduce readmissions by 66 percent
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