The Mount Sinai PPS has entered Demonstration Year 3 for DSRIP, which marks the second half of the five-year program. Leveraging the planning work that partners have done in the previous two years, we will be moving towards a phase of clinical implementation to maximize funding from the New York State Department of Health.

Therefore, in DY 3, MSPPS will work with a targeted group of partners to concentrate specifically on meeting clinical performance measures to optimize DSRIP funding opportunities.  

We are transitioning from working on individual projects, to focusing on the following three clinical areas:

 Please click here to download the list of our key clinical performance measures. 

Work from our ten clinical projects in the first two years aligns with these measures and you can find out more here. We look forward to continuing to work with partners in our network to better coordinate care for the patients in our community.

The Community Gateway is a web-based platform designed for MSPPS health care professionals to access innovative tools and applications for clinical transformation. While most partners at MSPPS may recognize the Community Gateway for its contracting functionality to access unique amendment information or submit reports for contracting, the Community Gateway goes beyond that and its distinctive technology will enable health care professionals to access clinical information, collaborate on patient care, and manage clinical performance with ease. We begin by engaging a select group of the healthcare team to further refine Community Gateway's capabilities. 

We are excited to announce that, to date, the Mount Sinai PPS has successfully on boarded nearly 600 users to the Community Gateway through our implementation work with the William F. Ryan Center! In collaboration with the Ryan Center, we are currently training Ryan Center staff, which will include clinicians, care team coordinators, quality improvement coordinators, and many more within the Ryan Center workforce. Additionally, we will begin piloting various Community Gateway applications at Mount Sinai St. Luke's and Mount Sinai West with social workers, nurse case managers, hospitalists, and soon, care teams in the ambulatory, emergency, psychiatry, and HIV departments.  

Team members from various administrative, clinical, and social services departments at Mount Sinai St. Luke's and Mount Sinai West attended and participated in a Community Gateway launch workshop.

"Community Gateway is an exciting and powerful application developed by and for the Mount Sinai PPS.  It will fundamentally transform how our providers communicate with each other, how they communicate with community based organizations, and how they deliver care to our most vulnerable patients," said Arthur Gianelli, President at Mount Sinai St. Luke's Hospital and Mount Sinai PPS. 

As we continue to the next phase of the implementation plan with other partners within the community, we will collect and analyze feedback to assist with roll-out plans and trainings within the PPS network. We are excited to see how our technology will help support clinical workflows and improve patient care.

For more information about Community Gateway, please e-mail [email protected] . 

One of our most immediate efforts is closing out the measurement period, which ends on June 30th, by engaging our partners in activities that will help the PPS improve its performance on the eight high-value measures. In order to meet the clinically focused DY3 measures and metrics, MSPPS has focused its efforts on our PPS's top six high-attribution partner organizations with the largest percentage of primary care providers. To achieve this goal, project managers have been working with these six organizations to:

As we move forward in the next few months, MSPPS will be engaging with a targeted group of partners in a phased approach for clinical implementation and performance achievement in our 3 clinical focus areas: chronic disease management; access, prevention and health promotion; and care coordination, transition, and management with readmission reduction.

Later this month, in partnership with City Health Works, the Care Transitions & Population Health Team at Mount Sinai St. Luke's (MSSL) and its Mount Sinai Heart Program will launch a care transitions pilot  program for patients with congestive heart failure (CHF).

Funded through Mount Sinai's partner dollars, the one-year pilot aims to reach 100 eligible patients, who will each receive individualized health coaching and care coordination from

City Health Works health coaches. Eligible patients are identified by MSSL hospital staff who refer patients that are in need of community-based self-management skills training to City Health Works. Eligible patients will have received a primary diagnosis of CHF during admission to MSSL hospital. They will reside in East, West, Central Harlem, or Washington Heights, and be at least 18 years of age. To capture the progress from the pilot and optimize patient care outcomes, the Transitions of Care team at MSSL, Mount Sinai Heart, and City Health Works will meet monthly to discuss clinical performance, operational workflows, and patient care needs. "After joining meetings with the CHF clinical team, they identified that many patients needed practical and culturally competent coaching about diet, medications, exercise and the importance of follow-up care, especially after hospitalization." recalls Dr. Theresa Soriano, Senior Vice President of Care Transitions and Population Health at MSSL. "A partnership with City Health Works, along with our traditional post-acute partners, fills this gap."

The pilot is a part of MSPPS' clinical implementation strategy towards building a hub, improving care transition efforts and reducing avoidable hospital readmissions. As such, this work will impact several key DSRIP performance measures including: the reduction in 30-day readmission, increase in compliance with follow-up appointment within 7 days to CHF rapid follow-up clinic, complete fulfillment of prescription refill by due date, and adherence with lab/disease monitoring.

As part of this collaboration, City Health Works health coaches were trained by nurse specialists from the MSSL Heart Team. "We are thrilled to partner with Mount Sinai and the Heart Program to jointly deliver the best quality care to patients. Our health coaches, who are hired from the neighborhoods that we serve, pride themselves on developing quality, trusting relationships with patients and helping them achieve the best outcomes," says Jamillah Hoy-Rosas, Director of Health Coaching & Clinical Partnerships, City Health Works.

MSPPS is excited about this unique pilot and our collaboration with community-based organizations! Please stay tuned for updates on this exciting work!

For more information about participating, please contact [email protected].

For partners who are not yet connected to a Qualified Entity (QE),  New York State Department of Health (NYS DOH) and New York eHealth Collaborative (NYeC) recently updated its Data Exchange Incentive Program (DEIP). A Qualified Entity is a centralized location where a region houses and shares its electronic health information. The goal of this program is to increase the use of Electronic Health Record interfaces to QE across New York State and create a more robust data collection in the Statewide Health Information Network of New York (SHIN-NY). The program aims to lessen the cost for an organization to connect to a QE, by incentivizing the use of seven data elements. These data elements include Encounters, Demographics, Medications, Labs, Allergies, Procedures and Diagnoses.

The program announced the following updates:

Please note the new potential incentive for healthcare organizations to connect to the SHIN-NY through DEIP is $13,000 per organization. For additional information please click  here.

Please contact a  Qualified Entity or [email protected] with any questions.

*An exception for FQHCs enrolled in the program will be made through 9/30/17

As we transition from DY2 to DY3, Mount Sinai PPS partner, Community Healthcare Network (CHN) demonstrates innovation in our journey towards improved clinical performance.

Community Healthcare Network is a joint-commission accredited, PCMH Level 3, not-for-profit organization that provides access to affordable, culturally-competent and comprehensive community-based primary care, dental, nutrition, mental health and social services annuall y to more than 85,000 individuals throughout New York City. Many of these men, women, and children would otherwise have little or no access to critical health care.  

	Photo Courtesy of Community Healthcare Network

CHN Programs that Puts Patients First 

Mount Sinai PPS partner, Apicha Community Health Center (CHC) celebrated the expansion of its services with a ribbon cutting ceremony on Wednesday, June 15 at its Chinatown-Tribeca location at 400 Broadway. Apicha CHC CEO Therese Rodriguez spoke during the event and called the opening a "bright spot." Rodriguez said, "Apicha CHC is here to make everyone feel like they belong so they can take care of themselves and others."

Due to the expansion, more patients will now have access to services offered by Apicha CHC. The addition includes seven street level exam rooms for primary care services and five lower-level private rooms for other services along with an on-site pharmacy.

Apicha CHC is looking to further expand its services in Spring of 2018. It will be opening up a second facility in Jackson Heights, Queens and will be offering primary care services for adults and children, dental services, mental health and life-stabilizing support services, and an LGBTQ meeting room. This project is funded through DSRIP's Capital Restructuring Financing Program and the New York City Economic Development Corporation's Community Health Center Pre-Development Support project. 

For more information on Apicha CHC please click here: https://apicha.org/

Does your organization have an upcoming event you would like us to highlight? Please email [email protected].