woman health care provider wearing a mask and talking with a patient in a home setting

Healthfirst takes a proactive approach to encourage health screenings and care for chronic conditions among seniors

The Challenge

There are more than 1.1 million adults over age 65 in New York City. (Source) Those who don’t regularly see their primary care provider face increased risk of cognitive decline, avoidable ER and inpatient visits, nursing home admission, social isolation – and are more likely to be forced out of their longtime homes.

Our Goal

To increase regular primary care visits among seniors to screen and care for chronic health conditions.

The Healthfirst Solution

Through the Helping You Program, agencies in three boroughs targeted 1,600 Medicare members who didn’t visit their primary care provider (PCP) in 2019. A coalition of managed care and community organizations worked with PCPs to close Medicare STARS care gaps and complete holistic health assessments. These health assessments included addressing a range of social and economic needs (food and SNAP benefits, exercise, transportation, and home repairs).

Population Health Improvements seen after six months

  • 6x increase in hemoglobin A1c testing
  • 4x increase in medication reviews
  • 3x increase in diabetic eye exams and functional assessments
  • 2x increase in pain screenings
  • Members retained access to care during COVID-19


Through the Helping You Program, we’ve seen that outreach to senior populations is proven to increase their access to needed care — even during a pandemic. Community-based workers are essential partners to health plans. They can help members meet nonclinical care needs and provide a level and frequency of engagement that traditional providers cannot.