High-need older adults and people with disabilities—at risk of hospitalization and/or long-term institutionalization—are one of the most important segments of the patient population for health care organizations. Their risks are strongly influenced by factors outside of the comfort zone of formal healthcare – the social and behavioral determinants of health. Readmission penalties, bundled payments, value-based purchasing, and other factors, all add urgency to creating a population health strategy for these patients.
That’s where the Aging in New York Fund’s CommunityCare Link (CCL) comes in.
In partnership with New York City’s Department for the Aging, we have organized some of the highest-quality aging services providers in the five boroughs to meet their needs. These organizations are rooted in the communities they serve, offering a deep understanding of their clients and the myriad of issues affecting their health. CommunityCare Link brings these providers together, ensuring that evidence-based services are provided to members, and that health payers’ reporting, oversight, and contract requirements are fully satisfied in a timely and efficient manner.