Overview

The purpose of this research study is to investigate if a personalized intervention including parts such as navigation (focus on patient outreach efforts, missed and completed encounters), personalization (individual health benefits) and compensation (value health-related costs borne by patients) will help people reduce their chances of dying from preventable causes, including heart attacks, strokes, drinking alcohol, substance abuse, HIV, and other conditions.

Eligibility

Inclusion Criteria:

1. Age 35 to 64
2. Low SES (≤ $38,000 annual income, based on 2019 20th percentile NYC income, adjusted for family size)
3. Expected mortality ≥1% per year (based on age, sex, race/ethnicity), with ≥1 of the following contributors:
   1. 10-year cardiovascular risk ≥10% (assessed by ASCVD risk tool)
   2. Heavy alcohol consumption (defined using SAMHSA binge drinking definition, drinking >4 standard drinks for men and >3 standard drinks for women on same occasion in past month)
4. Willing to be navigated to Health and Hospitals Corporation of New York health

   system.

5. Ability to provide written informed consent in English or Spanish

Exclusion Criteria:

1. Receives regular care elsewhere than Health and Hospitals Corporation of New York
2. Already diagnosed with high mortality-condition(s) that are not included in the simulation model.