Please make sure you have the patient's most recent and updated contact information and that patient consents to the referral

Program Description

Super utilizer clinic within IMA for patients at risk for preventable hospitalizations or ED visits.

PeakHealth is an intensive outpatient care program for patients at very high risk for avoidable hospitalizations and ED visits. Patients typically have both medical and psychosocial complexity and care is delivered in a multidisciplinary team which includes: MD, NP, LCSW, care coordinator, psychiatrist, LPNs, registrars, and AA.

The clinic is open access, M-F 9-4:30. Patients benefit from increased SW and provider availability (with visits as often as needed), care coordination, and increased visit time to allow for necessary and complex care coordination and health coaching. Dedicated AA, the mainline (4-PEAK or 212-241-7325), and direct contact with care coordinators' cell phones allow for improved communication with patients and families; the entire team can do home and community visits as needed.


Healthfirst patients only, at present. The first visit is a 'consult' to assess eligibility. Risk is assessed based on the patient's likelihood of repeat hospitalization, which takes into account prior hospitalizations, their degree of disease control, self-management skills, and psychosocial stressors. Patients who will benefit are enrolled till their disease tempo subsides, their self-management skills improve, and psychosocial aggravating factors become more manageable. Patients should expect that once they improve they will return to their previous PCP.

There is no minimum number of previous admissions necessary to be enrolled in PeakHealth. Patients may have had hospitalizations at Mount Sinai or elsewhere.

Patients typically have multiple recent admissions and:

  • Advanced chronic illnesses (CHF, COPD, DM, CAD, CKD, ESRD, etc), uncontrolled symptoms related to chronic illness, severe psychosocial stressors exacerbating chronic illnesses.

Please also consider alternatives for some patients:

-Patients with advanced active cancer may be more appropriate for the ONCOGENERALIST program

-Patients with an advanced terminal illness may be appropriate for a direct referral to Hospice or Palliative Care

-Homebound patients may be appropriate for Visiting Doctor's program

How to refer

Please answer the following questions:

  1. MRN/Name/DOB:

  2. Is this patient in VBC?

  3. Patient’s current phone #:

  4. Patient’s Primary Language:

  5. Would you like our providers to contact you to discuss the patient?

  6. Primary reason for referral: (ex. What can our team help with considering a 6-12mo intervention)

  7. Psychosocial/Medical barriers:

  8. Is social worker/Care Management involved? Who?