Mount Sinai PPS (MSPPS) has developed a social determinant of health screening (SDH) tool in collaboration with care management agencies, social work departments, federally qualified health centers, and a home care agency. The tool addresses several needs - including food/nutrition, housing, income, literacy, transportation, safety, and health care. 

The SDH tool was implemented with a pilot group of MSPPS partners over the past year. At the end of the pilot, partners unanimously agreed on the importance of SDH screening to provide better services and care for patients. Pilot partners are considering how to incorporate SDH tools in their workflows. Some partners discovered that SDH conversations were likely to occur with various members of the care team and not just the social worker or behavioral health provider. 

As a next step, MSPPS will continue to gather feedback from the pilot group to standardize and expand the screening tool across the network.  To learn more about the development of Mount Sinai PPS' SDH screening tool, please click here . 

In addition to the focus on achieving key performance meas ures to improve access to care and reduce hospital readmissions, Mount Sinai PPS is also focusing on integrating clinical efforts in our communities. We are collaborating with our community partners to develop innovative ways to address gaps in transitions of care. Together, we are implementing long lasting improvements to reduce unnecessary hospital readmissions and emergency department visits. 

Some of our current efforts include:

• Developing programs and activities that increase patient follow-up appointments 7 and 30 days after a mental health hospitalization;
• Improving the initiation and engagement of patients with substance use diagnoses in substance use disorder treatment;
• Improving transitions of care between inpatient settings and SNFs, CHHAs and FQHCs;
• Providing a Community Paramedicine program with rapid evaluation and in-home treatment for patients with acute symptoms;
• Piloting of community-based health coaching for congestive heart failure (CHF), diabetes and asthma admissions with City Health Works

On Tuesday, February 6th, Urban Institute hosted an event highlighting the work of City Health Works (CHW), discussing the critical role of health coaching to improve the health of patients with chronic illnesses and address their complex needs outside the doctor's office. Dr. Theresa Soriano, SVP for Care Transitions and Population Health at Mount Sinai St. Luke's Hospital and Clinical Quality Committee Co-Chair at MSPPS spoke at the event, sharing the Mount Sinai St. Luke's and Mount Sinai PPS experience in utilizing the health coaching model to address needs of patients with congestive heart failure. Supported by DSRIP, CHW and Mount Sinai St. Luke's Hospital are partnering on a pilot to reduce hospital admission for Medicaid patients with chronic diseases.

Hear more about it here  |  Learn more about the pilot here. 

The Brooklyn Hospital Center (TBHC) is addressing needs in its diverse community with the help of the Mount Sinai PPS (MSPPS) and DSRIP. With over 360,000 annual patient visits, this community teaching hospital serving Fort Greene, Flatbush-Ditmas Park, Bushwick, Greenpoint, Sunset Park, and Williamsburg, delivers primary, specialty, and behavioral health care, as well as dental services. 

	Photo Courtesy of The Brooklyn Hospital Center

With the help of the MSPPS, TBHC has reshaped its workflows, implemented new technology, and collaborated with other MSPPS partners to meet key DSRIP performance measures. 

DSRIP Partnership Encouraged Call Center Expansion and Workflow Redesign 

To drive MSPPS performance efforts forward, TBHC expanded its call center to not only receive calls to assist patients and providers, but to also reach out to help patients schedule appointments. The call center staff, which now includes patient navigators, reviews patient lists to identify patients who may not have been seen for a particular needed service. After an appointment has been scheduled, the staff member sends a note to the provider or medical assistant (MA) regarding the missing service. This helps achieve the goal of closing that care gap during the next visit.

Photo Courtesy of The Brooklyn Hospital Center

To support efforts to reduce avoidable hospitalizations and readmissions, TBHC participated in the New York State Department of Health Medicaid Accelerated eXchange (MAX) Series. As a participant, TBHC developed a workflow to support high utilizers, defined as patients who have been hospitalized more than four times in the last twelve months.  High utilizers often have a combination of medical, behavioral, and social needs. High utilization is a "symptom" of an unmet, unaddressed/ineffectively addressed, or unidentified need. In January 20 17, a multi-disciplinary workgroup was established to develop a workflow to identify eligible patients and create care plans that address unmet needs resulting in reoccurring admissions. In the last year, 297 patients have been identified as high utilizers. The pilot showed a reduction in admissions in the 90 days after becoming high utilizers. Many of the identified needs are social, thus emphasizing the need for partnerships with community based organizations. 

"Quality improvement is needed to promote healthy outcomes and through the PPS we are pushed to strategically think about how to achieve them in different ways," said  S heila Anane, Director of Innovation for Ambulatory Care Administration. 

Collaboration with NADAP to Expand Services to Patients 

James R. Knickman, PhD, President and CEO of the New York State Health Foundation (NYSHealth) interviewed Neil Calman, MD, President and CEO of The Institute for Family Health (IFH), a Mount Sinai PPS partner on the challenges and lessons learned since developing shared savings plans with multiple payers with the help of a 2012 grant from NYSHealth. The development of these contracts with each shared savings plans was essential for IFH to gain more robust patient data to inform them of the type of care their patients were receiving outside of IFH's facilities. While there continue to be many challenges throughout this process, IFH has developed shared saving agreements with five payers, covering about 19,000 Medicare, Medicaid, and commercially insured patients. The agreements allow access to more patient data to work on transforming the patient experience and reducing hospital utilization. To read more from the interview, please click here. For additional information on The Institute for Family Health please click here.

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