Longer primary care visits and risk scoring cut hospital use for Medicaid patients

A safety-net hospital in Queens, New York, has shown that a fundamentally redesigned form of primary care can keep its most vulnerable patients out of emergency rooms and hospital beds. In a study published in The Annals of Family Medicine, clinicians at Jamaica Hospital Medical Center describe a new care delivery model built around extended, high-value visits for Medicaid patients identified as being at the highest risk of needing acute care. The results, reported by a team led by corresponding author Alan Roth, DO, FAAFP, include reduced use of emergency and hospital services, improved management of chronic disease, and lower costs within the Medicaid managed population.

The population the model targets faces a convergence of challenges that conventional primary care is often poorly equipped to address. Medicaid patients in under-resourced communities frequently present with mounting care needs and poorly managed chronic conditions such as diabetes, hypertension, and heart failure. Layered on top of these clinical burdens are socioeconomic barriers, including unreliable transportation, unstable housing, food insecurity, and limited access to behavioral health services, that routinely prevent patients from receiving preventive care at all. By the time many of these patients reach the health system, they arrive through the emergency department rather than a scheduled appointment, at enormous cost to both their own health and the broader system.

Jamaica Hospital Medical Center’s ambulatory care department serves exactly this kind of population. As a safety-net hospital in Queens, it cares for a heavily Medicaid-insured community with limited access to specialist and primary care resources. Rather than attempting to stretch existing appointment structures thinner, the department’s leaders asked a different question: which patients are most likely to end up in the hospital or the emergency department, and what would it take to reach them before that happens? The answer became a comprehensive redesign of how the highest-risk patients experience primary care.

The first technical component of the model was systematic risk stratification. The department partnered with a third-party vendor to incorporate a risk-scoring tool into its workflow, using the tool to sift through the patient population and flag those at greatest risk of requiring emergency or inpatient care. Risk scoring of this kind typically draws on utilization history, chronic condition burden, and other data patterns to produce a quantified estimate of near-term risk. Crucially, however, the hospital did not let an algorithm make the final call. A multidisciplinary team of clinicians, case managers, patient navigators, behavioral health staff, and social workers reviewed the flagged patients, chose who to prioritize, and then planned and debriefed each round of visits as a group.

That team-based planning process is what transformed the risk scores into action. Once a patient was selected, the visit itself was rebuilt from the ground up. Instead of the standard brief appointment, patients received 40-minute high-value visits, more than twice the 18-minute average for primary care visits in the United States. The extra time was not simply a longer version of the usual encounter. Physicians and residents were trained to look past the diagnosis to what gives patients’ lives meaning, and to attend to the behavioral and environmental factors that may affect their health. In practice, that means asking about the circumstances of a patient’s daily life, the stresses and supports around them, and what outcomes matter most to the patient personally, rather than treating each visit as a narrow transaction focused on a single problem or prescription.

The second structural pillar of the model was the patient navigator. Navigators, hired with state funding through a Medicaid demonstration waiver, handled the practical work that so often falls through the cracks in safety-net settings. They conducted outreach to bring patients in, managed prescriptions, coordinated lab work, and arranged referrals to specialists and other services. Just as importantly, they were positioned to identify the concrete barriers that derail care plans: a patient who cannot get to an appointment without help with transportation, or whose housing situation makes medication storage and follow-up difficult. By surfacing these obstacles early and connecting patients to resources, navigators addressed the social determinants of health that clinical encounters alone cannot touch.

The combination of extended physician time and intensive navigation support produced measurable results. According to the study, the model led to reduced care use, meaning fewer emergency department visits and hospitalizations among the targeted population. It also improved chronic disease management, suggesting that the longer visits and closer follow-up allowed conditions such as diabetes and hypertension to be controlled more effectively before they escalated into crises. Finally, the model achieved lower costs within the Medicaid managed population, an outcome that matters deeply for safety-net institutions operating under persistent financial pressure. Preventing a single hospitalization can offset the cost of many extended outpatient visits, and the findings suggest that arithmetic worked in the hospital’s favor.

The implications extend well beyond one hospital in Queens. Safety-net hospitals across the United States serve patient populations with similar profiles: high chronic disease burden, heavy reliance on emergency care, and social circumstances that undermine routine outpatient management. The Jamaica Hospital model offers a replicable template that combines three elements, each of which has been discussed in health services research for years but rarely integrated so completely. Risk stratification identifies who needs help most urgently. Interdisciplinary team planning ensures that clinical judgment, behavioral health expertise, and social work insight all shape the response. And the redesigned visit, backed by navigators, gives clinicians the time and support to actually address what is driving each patient’s risk.

The model also speaks to a broader conversation about how primary care is valued and structured. The 18-minute average visit that the 40-minute appointments more than doubled reflects a system in which physicians are often reimbursed for volume rather than depth, leaving little room to explore behavioral health needs, social circumstances, or patient priorities. Training physicians and residents to ask what gives a patient’s life meaning represents a deliberate philosophical shift toward whole-person care, aligning with long-standing principles of family medicine. The study’s findings give that philosophy an empirical backbone: when the time is actually provided, and when navigators remove the logistical friction, deeper engagement translates into fewer crises and lower spending.

For Medicaid programs and state policymakers, the work carries an additional lesson about funding mechanisms. The patient navigators who anchored the outreach and coordination work were hired with state funding through a Medicaid demonstration waiver, the kind of flexibility that allows states to test service delivery innovations outside traditional benefit structures. The study, published in The Annals of Family Medicine with Alan Roth, DO, FAAFP, of Jamaica Hospital Medical Center as corresponding author, suggests that such investments can pay for themselves by reducing emergency and inpatient utilization. As health systems and payers search for ways to manage rising-risk populations, the Queens experience offers concrete evidence that reaching patients before they need emergency or hospital services is not merely an aspiration but an achievable operational strategy, provided the visit itself is redesigned to match the complexity of the patients it serves.

Subject of Research: A novel primary care delivery model for high-risk Medicaid patients in a safety-net hospital

Article Title: New care model that includes longer visits aims to reach patients before they need emergency or hospital services

Article References: New care model that includes longer visits aims to reach patients before they need emergency or hospital services. (n.d.). Original publication

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Keywords: primary care, Medicaid, safety-net hospital, risk scoring, patient navigators, chronic disease management, emergency department use, hospital utilization, health care costs, social determinants of health, Annals of Family Medicine, Queens New York