The Institute for Family Health, a New York City FQHC, has incorporated Healthix Clinical Alerts into hospitalization pre - dictive risk models to identify, intervene and treat complex patients at increased risk for adverse health outcomes. When the Institute received an alert from St. Luke’s Hospital for an ER visit from Brian*, a 60-year-old diabetic without a stable home who had 130 prior visits to multiple EDs within the year, a care manager rushed to the hospital. She walked Brian to their Harlem facility and immediately began plan- ning his services. That day, the Institute connected Brian to primary and behavioral healthcare providers, helped him apply for SNAP , and placed him in a Bronx homeless shelter. This rapid, high-touch intervention was possible beca

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