Community Outreach for Recovery and Engagement (CORE)
Community Outreach for Recovery and Engagement (CORE) provides targeted, person-centered interventions to help individuals become more engaged in their healthcare and to prevent unnecessary future hospitalizations. The program is designed to engage individuals who have a behavioral health diagnosis and a high rate of emergency room and/or inpatient services usage, and who are attributed to the Mount Sinai PPS (Performing Provider System).
Staff on the interdisciplinary CORE team work together to provide six-month interventions to program participants, with the goal of successfully connecting individuals to longer-term services. These interventions include outreach, engagement, community care, and transition of care.
CORE provides 24/7 call coverage, so participants have access to care at all times. In addition to a comprehensive assessment of client needs, services include:
- Home visits and hospital engagement
- Active involvement in discharge and aftercare planning
- Medication management and reconciliation support
- Benefits and entitlements support
- Collaboration with other members of the individual's care team and support network
- Linkages with community providers
- Appointment reminders and escort to appointments
- Transitional care support and effective handoff to longer-term services
This program is provided in partnership with the Mount Sinai PPS and the Coordinated Behavioral Care IPA.