Navigation Search




Return To Previous Page

Maimonides selected for national initiative to advance integrated care models for people with complex needs


Maimonides Medical Center is one of eight organizations chosen to participate in Advancing Integrated Models (AIM), a multi-site demonstration project promoting innovative, person-centered strategies to improve care for adults and children with complex health and social needs. Made possible with support from the Robert Wood Johnson Foundation and led by the Center for Health Care Strategies (CHCS), AIM will assist grantees in designing and piloting novel approaches to integration with a focus on improving outcomes and fostering health equity. Maimonides will use the funds to embed a risk-stratified care management model throughout its facilities and community that unites elements of the payor and program-reliant models Maimonides has developed through New York’s Medicaid Health Home and Delivery System Reform Incentive Payment programs. 

“The AIM project will allow us to look at the resources we’ve supported in the last two decades—peers, care navigators, care managers, transitional care teams, health coaches—and develop protocols to deploy them to the right patients at the right time,” said Karen Nelson, MD, Senior V.P. for Integrated Delivery Systems at Maimonides. 

“Some patients can be managed through a primary care practice with health coaching. Others will need comprehensive end-of-life care, or intense social or behavioral interventions,” explained Dr. Nelson. “Our newly refined model will identify these needs and provide the most appropriate care management intervention for each patient.” 

Other cornerstones of the model will include a centralized care navigation resource and monitoring of patients to ensure the level of services they are receiving correlates with their level of need.

Maimonides has been a trailblazer in population health strategies to address needs across the borough for almost fifteen years. The most notable of these undertakings include: 

  • Brooklyn Health Home which provides care management services to Medicaid patients with complex, chronic conditions since 2011
  • Community Care of Brooklyn, one of the state’s largest DSRIP Performing Provider Systems, comprised of over 1,000 health, social service, and community-based organizations working to reduce avoidable hospital use and improve health outcomes among the borough’s Medicaid beneficiaries, since 2015

The AIM project will deepen Maimonides’ commitment to population health by ensuring that a broader range of individuals can benefit from these promising practices.

“Maimonides has implemented several approaches to care management for discrete populations,” said Sara Kaplan-Levenson, V.P. for Complex Care and Population Health at Maimonides,” but eligibility requirements for these programs and lack of other reimbursement mechanisms restrict patients from accessing much-needed services.. It was this realization, in part, that spurred us to develop a model that could be truly patient-centered and transcend the constraints of existing approaches.”

For more information on AIM, please see here, or a press release from CHCS here.

About Maimonides Medical Center

As the largest hospital and significant provider of services to Medicaid beneficiaries in Brooklyn, Maimonides Medical Center has long invested in programs that further the triple goal of fully integrated medical care, mental health care, and social services. Through funding streams provided by New York State’s Medicaid Health Home and Delivery System Reform Incentive Payment programs, Maimonides has led the Brooklyn Health Home since 2011 and Community Care of Brooklyn since 2015. 

For more information on population health work at Maimonides, please see here

About the Robert Wood Johnson Foundation

For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being. For more information, visit

About the Center for Health Care Strategies

The Center for Health Care Strategies (CHCS) is a nonprofit policy center dedicated to improving the health of low-income Americans, especially for individuals with complex, high-cost needs. CHCS works with state and federal agencies, health plans, providers, and community-based organizations to advance innovative and cost-effective models for organizing, financing, and delivering health care services. For more information, visit