Please make sure you have the patient's most recent and updated contact information and that the 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 ambulatory care clinic for patients at very high risk for avoidable hospitalizations and ED visits. Patients typically have both medical and psychosocial complexity; delivery of care is within a multidisciplinary team that includes MD, NP, LCSW, Care Coordinator, LPNs, registrars, and AA.

The clinic is open M-F 9am-4p. 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. Patients have 24/7 access to the PEAK line (4-PEAK or 212-241-7325). During the day, phone calls are often responded to within minutes to hours.


We accept ALL payors and insurances. The first visit is a 'consult' to assess eligibility. Risk is assessed based on the patient's likelihood of repeat hospitalization, which considers prior hospitalizations, their degree of disease control, self-management skills, and psychosocial stressors. Patients who will benefit are enrolled until their disease tempo subsides, their self-management skills improve, and aggravating psychosocial 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 chronic illness symptoms, and severe psychosocial stressors exacerbating chronic illnesses


  • 2 or more hospitalizations in the past 6 months
  • 3 or more ED visits in last 6 months
  • A1c > 9
  • other social determinants: needs for higher CC, med non adherence, multiple no-shows, poor health literacy


  • New Healthfirst Medicaid
  • Sickle Cell
  • Active Malignancy
  • Primarily psychiatric referral
  • Pregnancy
  • Active substance abuse
  • Homebound patient
  • Residing in a long term facility

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 the Visiting Doctor's program

How to refer

Referral to PEAKHEALH can be sent in Epic

Search for "Ambulatory Referral to IMA PEAK Health" and fill in the questions in the "comments" section