ELMIRA, NY.  (WENY) -- Arnot Ogden Medical Center is one of two area hospitals taking part in a program designed to reduce frequent hospital visits.
The state-funded project apart of the five-year "Delivery System Reform Incentive Payment Program," aims to improve patients health, while also reducing Medicaid costs.

"It's preventing illness and it's maintaining health," says Arnot Health CEO, Dr. Robert Lambert. "[There's] three things to remember there: better health for the community, which is a vital need in our community, better health care and all at lower costs."

The root of the program is identifying why people are returning to hospitals so frequently.

"We do a deeper dive to see what these social needs are," says Dr. Pallavi Kamjula, Medical Director of Care Coordination of Arnot.

"If you don't have a stable roof over your head, you can't be healthy, frankly," says Lambert. "That extends to food--having a source of food and the rights foods. It goes further in other directions as well, such as transportation."

For example, the program has worked with Catholic Charities to find housing for patients.
Since being implemented at Arnot Ogden just over a year ago, medical staff say they've already seen significant results.
Patients identified as "high-utilizers" have reduced visits by 75%.

"This project has forced us to break down the silos between the hospital, the primary care offices and the community based organizations," says Lambert. "We are all working as a team because we're all bringing services to this patient."

While the program only applies to Medicaid users, the hope is to eventually benefit all aspects of healthcare and lessen the burden for taxpayers.