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Population Health

Maimonides Medical Center's Department of Population Health aims to improve the health of the Brooklyn community through transformation of the health care delivery system and the development of processes to support integration, coordination and collaboration across a wide range of health and social services organizations.

Maimonides has a long track record leading initiatives to improve population health, and provide high-quality care for individuals with chronic illness. Over the past few years, Maimonides' leadership in population health management has been widely recognized, both in New York State and across the country, as a result of its innovative approach to the creation of sustainable models of population-based care. This care is broader than the provision of medical services; we have developed with our community-based partners across Brooklyn, strategies to integrate and coordinate healthcare and social supports for individuals with complex medical and behavioral health illnesses. These innovations have shown promising results in terms of both quality and cost.

Brooklyn Health Home and key initiatives

Population Health services are aided by the exchange of electronic health information among providers, particularly in connection with meeting the needs of the population of chronically-ill patients. A partnership convened by Maimonides was one of the first "Health Homes" designated by the NYS Department of Health. The Brooklyn Health Home now provides care management services for over 8,000 Medicaid beneficiaries.

The Population Health team provides support to a number of current initiatives, including: Health Home; Patient Centered Medical Home program; Health Care Innovation Award project; and New York State Delivery System Reform Incentive Payment Program (DSRIP), among others.  The team also focuses on community health planning and the development of new healthcare delivery and payment models.

Much of the Population Health team's work to date has been to expand access to primary care and behavioral healthcare, and on developing innovative ways to integrate these services by bringing together groups of providers to solve complex problems. In addition to improving access to care, the Department of Population Health focuses on the social issues - including housing, substance use and incarceration - that can make staying healthy especially challenging. Our programs address mental illness, chronic illnesses such as diabetes and asthma, social vulnerabilities and building bridges between different care providers like hospitals, nursing homes, doctors' offices, shelters and jails. To bring the right care to the right people at the right time, the Department of Population Health works with a vast network of other providers throughout Brooklyn, including healthcare providers, community-based organizations and social service agencies.

We are excited to see our work in population health management continue to grow, strengthen and influence others in their approach to improving care and quality, and reducing costs.