Bronx Frequent User Initiative

Individuals who frequently use hospitals and emergency departments for avoidable reasons, often suffer from multiple and debilitating co-occurring chronic medical, social and behavioral health conditions that greatly contribute to their unmet health needs. Additionally, they experience many negative social determinants of health: poverty, homelessness or unstable housing, unemployment, and social isolation.

With funding from the Altman Foundation, United Hospital Fund, and Bronx Health Access Performing Provider System and in partnership with the Corporation for Supportive Housing (CSH), the Bronx Regional Health Information Organization (Bronx RHIO), several managed care organizations, and the New York City Department of Homeless Services, the Bronx Frequent Users of Systems Engagement (BronxFUSE) initiative works to identify and understand the needs of homeless high utilizers and prioritize them for a housing placement. This initiative is modeled on CSH’s national FUSE initiative, which helps communities break the cycle of homelessness and crisis among individuals with complex medical and behavioral health challenges who are the highest users of emergency rooms, jails, shelters, clinics and other costly crisis services.

The main goals of BronxFUSE are to: (1) conduct a study of homeless high-utilizers of Medicaid through a cross-system data match, and (2) establish partnerships between managed care organizations (MCOs) and supportive housing providers to prioritize this population for a housing intervention.

Cross-matching Medicaid utilization and homeless services data

In order to better understand the scope of high utilizers of Medicaid who are homeless, the project includes a data match and study. In Phase I of the data match, three participating MCOs––Affinity Health Plan, Amida Care, and Empire BlueCross BlueShield HealthPlus––identified their top 150 highest utilizers in 2016 and 2017, looking specifically at emergency department and inpatient utilization. That data, through our partners at the Bronx RHIO, was shared with the NYC Department of Homeless Services and matched with their records of shelter and street outreach use, and finally returned to the respective MCO. This gave us a cohort of high utilizers who had histories of homelessness. 

During Phase II of the data match, the MCOs will do a deeper dive into their data for those members who have histories of homelessness, providing encounter-level information that will shed light on their diagnoses and what is driving their hospital utilization.

Establishing partnerships between MCOs and Bronx housing providers


The second goal of BronxFUSE was to move some of the people identified through the data match into housing. Our participating four MCOs and three housing providers established partnerships, enabling each MCOs to share member information with their partner housing provider so that they could identify members who might be appropriate for available housing vacancies. Through funding from the Bronx Health Access performing provider system, each partnership was provided funds from a flexible spending pool that were used to support a client’s transition into housing, for instance to purchase furniture or pay a security deposit. We will be tracking outcomes for those who move into housing and analyzing their Medicaid utilization pre- and post-housing.

We hope that the process of developing these partnerships through this pilot project will lead to ongoing and expanded collaboration, with the potential for value-based payment arrangements.