Mount Sinai Health System’s St. Luke’s Hospital has been looking for a way to decrease readmissions among its recently discharged heart failure Medicaid patients.

The hospital’s 30-day readmission rate of 20% to 25% among such patients was comparable to national statistics within national averages. But a growing Medicaid patient population in New York’s Harlem neighborhood coupled with a systemwide push to incorporate more population health strategies within its clinical settings led to a search for a better way to help heart failure patients manage their conditions outside of the hospital.

“It was a good and important time to make sure that we were integrating some of these social need interventions as well as connection to the community in really trying to address root causes,” said Dr. Theresa Soriano, senior vice president of care transitions and population health at St. Luke’s.

That was the impetus behind St. Luke’s pilot program launched in July aimed at reducing hospital readmissions among Medicaid beneficiaries with congestive heart failure by educating patients how to better self-manage their conditions at home.

The program will provide individualized health coaching to 100 Medicaid beneficiaries in three adjacent city neighborhoods: Harlem, the Upper West Side and Washington Heights. Community health workers trained by nurse specialists on St. Luke’s cardiac-care team will provide individualized coaching to patients on the health issues and warning signs related to heart failure, such as the importance of checking weight and limiting fluid intake.

The one-year initiative is a collaborative effort between Mount Sinai and City Health Works, a Harlem-based not-for-profit organization started in 2012 that trains community members to be health coaches. Coaches meet patients at their homes or within the community and work with clinicians on care plans. CHW currently works with about 400 patients, with coaches also serving as a bridge between healthcare professionals and the community by communicating with clinicians about any social factors they find that may be hindering a patient’s progress toward achieving their health goals.

City Health Works founder and Executive Director Manmeet Kaur said the collaboration with St. Luke’s came about as a result of CHW’s past success working with outpatient providers on improving their patients’ management of conditions like diabetes, hypertension and asthma. According to CHW, health coaches were responsible for helping to identify a medical issue unknown to a provider in half of patients they served.

She said the hospital will evaluate the program over the next six months to measure primary and secondary outcomes. Mount Sinai hopes to expand the service across the entire system based on the results. Kaur said plans were already underway to scale up CHW to offer its services to providers in areas of Brooklyn and the Bronx.

Kaur said CHW has to date been largely funded with philanthropic support as the organization developed its care model, but she said the organization is prepared to make the transition of scaling up to take on contracts for its service.

She saw CHW as an ideal service for those healthcare providers that have already transitioned a significant share of their patients covered in risk-based contracts.

“We’re now at the stage where we’re operationally preparing for that type of scale-up in other states in addition to growing in New York,” Kaur said.