Health systems are investing in care coordination programs for patients who visit the emergency department most often, many of them for needs the ED can’t meet. By connecting patients with housing, food, transportation, behavioral health and medical services, the goal is clear: keep patients in their communities and out of the hospital.
At Danbury (Conn.) Hospital, part of New Hyde Park, N.Y.-based Northwell Health, that approach is producing measurable results. In fiscal 2026, which ran from Oct. 1, 2025, to Sept. 30, 2026, ED visits fell 60% among Community Care Team clients six months after enrollment, and inpatient admissions fell 79% at the same mark, according to the hospital.
“They were using healthcare resources not just because they had healthcare problems, but also for social supports,” said Charles Herrick, MD, McGraw family endowed chair of community and behavioral health at Danbury Hospital. “Patients come to emergency rooms making complaints about a physical problem when, in fact, what they need is a warm place to stay for the night because it’s freezing, or they need a sandwich because they’re hungry, and they don’t know where else to turn.”
For about a decade, Danbury Hospital’s Community Care Team has worked to meet those needs before they become another ED visit.
The program reaches patients who typically have logged six ED visits in six months before they are referred. Its approach is less a clinical intervention than a standing meeting: hospital staff, housing officials, food and social service agencies, behavioral health providers, EMS and police, all working the same list of names.
Built on the ‘hot spotter’ idea
Dr. Herrick, who has spent 28 years at Danbury Hospital and became its psychiatry chair in 2006, traces the model to surgeon and writer Atul Gawande, MD, and his 2011 article, “The Hot Spotters,” published in The New Yorker.
“It’s sort of the 80/20 rule, where 20% of the patients command 80% of the resources,” he said.
Those patients tend to be complex, with several medical and psychiatric conditions layered on housing instability, food insecurity and missed outpatient appointments. Because the ED is where their care costs the most, the program starts there.
Dr. Herrick does not claim authorship of the model. Community care teams began in Connecticut at Middlesex Hospital in Middletown, Conn., moved to Norwalk (Conn.) Hospital under a former psychiatry chair there, then came north to Danbury. The model has since reached Vassar Brothers Medical Center in Poughkeepsie, N.Y., he said. Danbury, Norwalk and Vassar joined Northwell when it merged with Nuvance Health; Dr. Herrick now also serves as network chair of psychiatry for Northwell’s Northern market.
One list, one table, once a month
Patients surface through the EHR, which flags high utilizers, and through ED and emergency psychiatry staff, who notice the same faces. Six visits in six months is the usual threshold, but clinicians can refer earlier. A patient admitted to medicine or psychiatry may not meet the criteria yet, Dr. Herrick said, “but we know that this is where things are heading if we don’t address the patient’s needs.”
Enrollment requires consent, and a navigator usually makes the ask in person, often at the bedside. Dr. Herrick described the message patients hear: “We understand you have all these medical problems that require outpatient services, but you’re not going to your doctor’s appointments. And we’re finding out that you’re homeless, and we’re finding out that you have trouble acquiring food. So we’re going to put a bunch of community resources together to address all these other problems that are pushing you toward the emergency room.”
Most patients agree, he said.
From there, enrolled patients go on a list that the full team works through at a monthly meeting. Among the participant are the local housing authority, social service staff who can enroll patients in Medicaid, nonprofit mental health and substance use providers, community health centers, food organizations, EMS and police.
Police attend because many of these patients come to their attention first, often over misdemeanors. “What can they do? They can bring the person to the emergency room, but they can’t really provide any other kinds of services,” Dr. Herrick said. At the meeting, officers can help identify people in need and route them to agencies that can help.
The group triages the list and parcels out the work in real time. One patient cannot connect with a social service agency, another cannot get a physician’s appointment. Dr. Herrick described how a third case might go around the table: “This person is having problems with their landlord, who’s threatening to kick them out because they’re creating problems in the neighborhood. OK, we’ll look at that. We’ll talk to the landlord.”
Hospital-employed navigators guide patients through the health system. Navigators at the partner agencies handle transportation, get patients to appointments and help fill out paperwork such as housing voucher applications, which Dr. Herrick said is where much of the heavy lifting happens.
Beyond the reductions in ED visits and admissions, the program tracks new connections to physical and mental health providers, housing and transportation services, and patient satisfaction.
Funded by donors, tested by coverage losses
The Community Care Team runs entirely on philanthropy, according to the hospital, alongside Northwell’s broader investment in community behavioral health. Donors give, Dr. Herrick said, “because they believe in it. It’s demonstrated success, and this is the most vulnerable population that we work with.”
That population is also the one most exposed to the coverage changes now reaching hospitals. HR 1, the One Big Beautiful Bill Act, is projected to reduce federal Medicaid spending by nearly $1 trillion. By 2034, the number of uninsured individuals would grow 11.8 million more.
Dr. Herrick said people with mental illness face particular risk under Medicaid work requirements. Their conditions make it harder to hold a job, keep housing and secure food, yet to those reviewing eligibility they may not look sick, and so look like they could work.
He expects the effects to show up in the ED, and said hospitals have already begun to see an uptick in ED visits among uninsured patients. Working people priced out of marketplace coverage are part of that picture, too.
“They’re going to be using ED services in emergencies because they can’t pay for preventative health either,” Dr. Herrick said. “There’s a ripple effect that will ultimately, unfortunately, increase the cost of healthcare throughout the nation.”
Northwell has not stepped back from community mental health spending as it looks for savings elsewhere, Dr. Herrick said, because the system sees that care as a way to lower costs in its hospitals and EDs over time.
For leaders weighing where behavioral health dollars go as coverage tightens, the model’s core ingredients are modest: a shared list, a standing meeting and community partners willing to take a name off it.
“It’s really a combined effort on the part of everybody to meet the needs of the patients in the community, so that they don’t have to come to the hospital to receive the care that they need,” Dr. Herrick said. “That’s the conception of the community care team in a nutshell.”
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