Primary Care Practice Redesign Newsletter
Cohort 1 | Issue 8
April 22, 2019
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This newsletter is a biweekly forum to keep practices
connected and informed on the Cohort 1 Redesign efforts.
Be sure to right-click to download pictures.
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With three months to go, you're well on your way to completing this first phase of your cohort's redesign!
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Take a moment and think of what you’ve accomplished to date as the first cohort of the Primary Care Practice Redesign—and thank you for keeping the momentum going!. Your input on this initiative and feedback on our surveys will help shape this program for the rest of the primary care practices and we are grateful for your collaboration and contribution to this effort.
Please keep your calendars open for the final Learning Collaborative on June 25, 2019 and we look forward to seeing you there!
Cohort 1’s practices are well on their way to completing the five projects below. Next up is
Transitions of Care
, which will be introduced by your Practice Facilitators, George Lourentzatos and Chris Scalamandre.
Redesign Projects
- PI and QI Training
- Care Wellness Survey
- Same Day Access
- Daily Huddles
- Transitions of Care
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PeakHealth: A Team-Based Model of Care
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Interview with Bernard Ortega, Program Administrator
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PeakHealth is a Mount Sinai clinic co-located with Mount Sinai’s IMA practice at 17 East 102nd Street, where high-need, high-risk, high-cost patients with medical and psychosocial complexities get the enhanced support they need to manage their health. This program is currently open to Healthfirst patients.
Team-based care model for high-risk patients
“Patients referred to our program often have a history of high utilization, frequent ED visits and hospitalizations, suboptimal adherence to their medication and treatment plans, and less than ideal connections to primary care,” stated Bernard Ortega, Program Administrator. “Our team of primary care providers, social workers and care coordinators work and communicate very closely together to advance our patients’ medical and psychosocial goals, and overcome barriers.”
Because PeakHealth is embedded at IMA, there is room for aligning core teams with teams within IMA and that is facilitated by PeakHealth staff joining in on IMA huddles. Additionally, once weekly, much like inpatient rounding, the PeakHealth care providers protect their time so that all care teams can do a patient disposition review. PeakHealth’s goal is to ultimately transition or “graduate” patients back to their original/referring PCP and close connection and communication is kept with the patients’ primary care providers.
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Establishing patient goals
Every patient undergoes a standardized intake process that includes a psychosocial assessment. Areas of need are identified, patients are evaluated on their willingness to make changes, and most importantly, we ask what our patients want to work on. “Our goal is to help patients become as self-reliant and independent as possible in managing multiple chronic conditions, but we first start with what matters most to our patients. We aim to celebrate the accomplishment of these goals, whether it’s successfully showing up for a specialist appointment, or learning when and how to take an inhaler for COPD,” remarked Bernard.
He continued, “Our program has been called an ambulatory ICU in the literature, and that captures what we do. We are a transitional program with the goal of stabilizing our patients and then safely discharging them back to their PCP. The criteria we use are whether the patient is more stable, can self-manage better, and whether they have achieved their health goals.” A patient goal can range from lowering their A1C level to being well enough to play with their children or abating mold in their home to improve their asthma. The fact that patients are interviewed to set specific, achievable goals, and that they commit to a plan helps make the program successful.
Patient satisfaction, patient involvement
In addition to 99th percentile Press-Ganey scores, patient satisfaction with the PeakHealth program is measured through a survey tool and PeakHealth has achieved a 95% net promoter score – a testimony to the respect and support they offer their patients. Unique to the program is a Patient Advisory Committee where patients can make recommendations to the program. PeakHealth is currently looking into developing a peer-led support group where graduates of the program can assist and coach current members in meeting their goals.
Referring a patient to PeakHealth
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Your satisfaction matters!
Please complete your Primary Care Wellness Interim Survey by April 24, 2019.
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Becker’s Hospital Review Names Niyum Gandhi One of 32 Chief Population Health Officers to Know
Please join us in congratulating our Executive Vice President and Chief Population Health Officer, Niyum Gandhi, on being named one of Becker’s Hospital Review’s 32 Chief Population Health Officers to Know across the country.
Niyum Gandhi is a sponsor and champion of the Primary Care Redesign project.
Niyum stated, “This is an incredible recognition and I must say I have been really fortunate to be a part of a very dedicated team at Mount Sinai Health Partners. Not only are they innovative but they are also relentless about improving the way we provide care to our community. They’re constantly finding new ways of transforming the care delivery model through different lenses – considering the experience and challenges of patients, doctors, employer groups, and just about anyone that is impacted by health care.”
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Transformation in the News
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New Strategies for Condition Management within Value-Based Care
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MSHP’s Chief Medical Officer, Dr. Robert Fields, published an article on managing chronic conditions with behavior change, new data sources, and new clinical roles in
Generations,
the Journal of the American Society on Aging. In the article, Dr. Fields shows how new technologies can promote behavioral changes and how the relationship between delivery systems and community organizations that recognize the importance of social determinants of health all lead to better health outcomes.
Read the article here
or
click here
for the full issue.
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Tip of the Day: Effective Huddle Strategies
Short, daily huddles are a great way to plan for more efficient patient visits and better quality care. Watch this
3-minute video
on how Mount Sinai’s 1090 Amsterdam Avenue primary care practice prepares for and implements its daily huddles and download this editable
checklist prepared by Dr. David Coun
of Mount Sinai Doctors Brooklyn Heights that you can use in your own practice.
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Senior Manager for Practice Improvement, Neha Dubli, and Dr. Fields discuss engaging providers in population health on the latest episode of the MSHP podcast. Neha shares her journey into population health via Uganda and New Orleans as well her role today within the health system. They discuss navigating pain points with providers, staffing optimization, burnout, designing care for the next generation, and more.
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