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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 AAs.

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 AAs, a main line (4-PEAK), and direct contact with care coordinators cell phones allows for improved communication with patients and families; the entire team is able to 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 illness.

  • Please also consider alternatives for some patients: Patients with advanced active cancer may be more appropriate for ONCOGENERALIST program Patients with advanced terminal illness may be appropriate for direct referral to Hospice or Palliative Care Homebound patients may be appropriate for Visiting Doctor's program

How to refer