Case Study: Brooklyn Health Home achieves faster care coordination and fewer hospital admissions with InterSystems HealthShare (InterSystems)

Tapping into a Health Information Exchange to Manage the Healthcare Needs of a Complex Population

Brooklyn Health Home (BHH) is a New York State Medicaid Health Home coordinating care for more than 8,000 Brooklyn residents with complex medical, behavioral, and social needs—many are homeless or have serious mental health conditions. BHH needed timely, community-wide visibility into emergency and inpatient events across hundreds of providers to coordinate care, prevent avoidable admissions, and ensure safe transitions for a high-risk population.

By tapping Healthix, a regional health information exchange built on the InterSystems HealthShare platform, BHH integrated real‑time Clinical Event Notifications into its care coordination system so care managers receive admission and discharge alerts and clinical summaries. Within seven months first-day response rates rose from 20% to nearly 60% and first-week post-discharge encounters approached 60%, leading to faster care planning, better provider collaboration, improved medication management, and reductions in ER visits, admissions, and readmissions.

Brooklyn Health Home

Patricia M.

Founder