Gloria Yanni was admitted to the emergency room nine times since January 2017. Since Ms. Yanni's participation in July 2017 in the congestive heart failure (CHF) pilot between Mount Sinai St. Luke's (MSSL) and City Health Works (CHW), she has not been readmitted and she has been learning how to properly manage her health. 

The one year pilot program brings together health coaches from City Health Works and nurse specialists from the MSSL's Heart Failure team. The health coaches are trained on important information about heart failure and key self-management tools for these patients. 

Ms. Yanni is the first patient for this pilot and together with her coach, Hilda Mejias, she has learned how to properly monitor her daily weight and the correct way to measure her total liquid intake with a measuring cup. Before meeting with Ms. Mejias, Ms. Yanni thought she should only be measuring her water intake, but recently learned that she needs to measure all liquids consumed including sodas and juices. 

MSSL Heart nurse practitioner, Cathleen Varley, said of this partnership,"The health coaches act, in essence, like a community extension of the care team. They team up with their patients, to remind and empower them about the skills they have been taught, so they can manage their heart conditions on their own when the coaches aren't there." 

Since the start of the program in mid-July, the pilot has engaged eleven more patients. The Care Transitions and Population Health and Heart Failure Programs at MSSL and CHW are meeting monthly to assess the pilot and the progress of participating patients. 

To learn more about this pilot, please read our press release here. 

As MSPPS focuses on clinical implementation during the  remainin g years of DSRIP, our current participation in the third demonstration year (DY3) of DSRIP (April 2017 to March 2018) proves to be a critical time identifying key performance strengths and opportunities. 

In July, MSPPS r eceived the performance results for Measurement Year 2 (July 2015 to June 2016) in which we achieved 76% of pay for performance funding. The PPS met the annual improvement targets for the following PPS priority measures, which were also measures for pay-for-performance (P4P) rewards in Measurement Year 2.

• Diabetes Monitoring for People with Diabetes and Schizophrenia
• Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication
• Prevention Quality Indicator # 1 (DM Short term complication)
• Prevention Quality Indicator # 7 (HTN)
• Potentially Preventable Emergency Department Visits (for persons with BH diagnosis)

MSPPS collaborated with a set of high attribution partners in targeted efforts to close gaps of care for the highest value performance measures for MY3 (July 2016 to June 2017).

 

Since 1967 The William F. Ryan Community Health Network (Ryan) has been providing a wide range of medical services to underserved communities in Manhattan and most recently celebrated its 50th year anniversary of services this past June. 

This Federally Qualified Health Center (FQHC) is comprised of six main sites, six school-based health centers, and six community outreach centers that offer mental health, pediatric, adult medicine, women's health, and other specialty services. In 2016, Ryan served over 45,000 patients  with almost 200,000 visits. To manage such a diverse and large system, Ryan's strategies advance innovation and quality improvement.  Staff are continuously evaluating processes and reviewing both qualitative and quantitative feedback to improve internal clinical processes and communications. Ryan's innovation can be attributed, in part, to Ryan's strong emphasis on teamwork. Recently, the quality improvement team, the outbound call team, patient service representatives (PSRs) and nursing staff performed outreach to reduce care gaps, which greatly impacted Ryan's quality scores and incentives. 
 

On September 14 , Betances Health Center in Manhattan hosted a community event with the Health Resources and Services Administration (HRSA) to announce the funding expansion opportunity of $17 million awarded to multiple community health centers in Region II locations, comprising of New York, New Jersey, Puerto Rico, and US Virgin Islands. The funding supports increased access to mental health services and substance abuse services focused on the treatment, prevention, and awareness of opioid abuse. At the event, patients and representatives from Betances Health Center provided testimonials about how this funding increase will affect services for patients. 

According to the Centers for Disease Control and Prevention (CDC), 91 Americans die every day from an opioid overdose. With this additional funding, community health centers will have the opportunity to impact this statistic by increasing personnel, leveraging health information technology, and providing trainings on prevention and awareness of opioid abuse. Betances is one of many Federally Qualified Health Centers to receive this funding. HRSA awarded more than $200 million to 1,178 health centers and 13 rural health organizations throughout the United States. 

For more information on Betances Health Center please click here. You can also find them on Facebook at Betances Health Center or Instagram at Betances280henry.

Buena Vida Continuing Care and Rehabilitation Center, a residential healthcare center and Mount Sinai PPS partner, was recently awarded a Quality Rating of five stars and an Overall Star Rating of three stars from The Centers for Medicare and Medicaid Services for its dedication and quality of care provided to patients. We congratulate the staff at Buena Vida for accomplishing this milestone and for their efforts to constant improvement while providing compassionate, warm, and experienced care.

For more information on Buena Vida, click here.

In August, Mount Sinai PPS and St. Luke's Hospital President Arthur Gianelli participated in a panel discussion at the "Getting Population Health Right: Critical Areas for Innovation" conference at the Mount Sinai Icahn School of Medicine. Greg Burke, Director Innovation Strategies from United Hospital Fund and Ram Raju, Senior Vice President from Northwell Health also joined Mr. Gianelli and provided their thoughts on population health implementation. During his presentation, Mr. Gianelli highlighted the importance of DSRIP sustainability to advance population health efforts. 

Mr. Gianelli revisited the initial goals of DSRIP and said, "We wanted to build a network of providers and community-based organizations that are connected with one another in care coordination and technology infrastructure." 

Mr. Gianelli highlighted the opportunities that DSRIP will offer for providers to work together in innovative ways towards better care and outcomes for our patients. Some of the MSPPS' initiatives include the Community Gateway technology, applications like Patient 360 that will give providers actionable data and insights into their patients' health and social determinants of health. Community Resource Guide, another application that will provide care management providers access to local resources to support patient needs and social determinants of health. Pilot programs such as health coaching from City Health Works for congestive heart failure patients and Community Paramedicine highlight new local partnerships to aid patients in our community. 

Although Mr. Gianelli recognizes that MSPPS' efforts are on the right path to addressing some of the challenges of providing better care to our vulnerable populations, he admits that there is still more work to be done to connect the different patient populations in New York City. He said, "Building bridges between the provider system, the jail, the court system and the public health system has only been addressed tangentially and in my view, not effectively."