Community Partnerships Community Partnerships

Community Partnerships


The Mount Sinai Performing Provider System (MSPPS) is committed to understanding the needs of our partners, providers, and patients to build programs that will create meaningful impact in our community well beyond DSRIP. The results from our 2016 Clinical Integration Readiness Survey along with recent conversations with PPS partners have highlighted and underscored the overwhelming need for social services to support our partners in providing better more well-rounded care to our patients. DSRIP has set the foundation for collaboration and MSPPS has been able to be a part of this ground breaking journey to create programs with our partners for our community. We are excited to introduce these programs and resources to our community. We will be sharing updates on this page about these initiatives. If you have questions, please contact

Some of our efforts include...

New York Common Pantry Offers Food Pantry Services throughout New York City 

New York Common Pantry (NYCP), one of New York City’s largest single-site community based food pantries, is expanding its mission to reduce hunger throughout New York City while promoting dignity and self-sufficiency. Through DSRIP funding, NYCP is expanding a few of its programs including: 

  • Project Dignity Program, which supports homeless individuals with basic needs and care management referrals. 
  • Choice Pantry Program, which focuses on helping participants choose culturally appropriate, nutritionally balanced food they would like to receive. 
  • Help 365 Program, which assists individuals with access to resources and other social services including the Supplemental Nutrition Assistance Program (SNAP), and Social Security Supplemental Income. 



Decreasing Hospital Admissions for Behavioral Health Patients through Short Term Respite Services

ACMH is providing short-term referral-based crisis respite services for patients experiencing a mental health crisis. This pilot project offers behavioral health patients crisis respite services following an inpatient stay, or as an alternative to hospitalization. During their stay, patients receive a wide range of services ranging from daily living skills to entitlement assistance, and includes around-the-clock support from peer counselors. This program went live in April 2018. Interested partners can contact


City Health Works Health Coaching Program Available for Patients with Chronic Illnesses

Through DSRIP funding, City Health Works will provide eligible patients with locally hired health coaches for six months. The health coaches will provide patients with health education, care coordination, and support to help patients manage their chronic conditions.  During these six months, patients will receive coaching sessions and some home visits to ensure that they are staying on track with health goals and are managing their chronic conditions.

Patients are eligible if they:

  • Have one or more of any of the following conditions that are uncontrolled: Diabetes, Hypertension, Asthma, and Congestive Heart Failure.
  • Have more than one emergency department or inpatient visit in the past 12 months.
  • Live in Manhattan.
  • Are at least 18 years old.
  • Referred from an outpatient setting.

Patients with serious cognitive issues/mental illness, gestational diabetes, active cancer treatment, end-stage disease, active alcohol and/or substance abuse are not eligible to participate in this program. To learn more about the program or to refer your patient(s) to City Health Works, please contact David Strefling, Health Coach Supervisor at or 917-903-3691. 


LegalHealth Collaborates to Provide Legal Services to Reduce Hospital Readmissions 

LegalHealth, a division of the New York Legal Assistance Group (NYLAG), is collaborating with Mount Sinai PPS partners, Settlement Health in East Harlem and the Ryan Health on the Upper West Side, to address socioeconomic and healthcare disparities through legal counseling. LegalHealth will provide free on-site legal assistance to patients at Settlement Health and Ryan Health. In addition to bi-weekly legal sessions, LegalHealth will also train Ryan Health and Settlement Health staff to identify when legal intervention and referrals are needed. 


Home-based asthma programs available to reduce hospital admissions by addressing environmental factors impacting asthma patients

Little Sisters of the Assumption (LSA) and AIRnyc will provide home-based asthma services to Medicaid patients with persistent and uncontrolled asthma. LSA and AIRnyc are using DSRIP funds to support these services. Through home visits, patients receive assessments on environmental factors impacting their asthma condition and learn strategies to manage asthma triggers and symptoms. LSA is available to patients who reside in East Harlem and AIRnyc is available to patients in other parts of Manhattan, Queens, and Brooklyn. 


Mount Sinai Collaborates with Community Barbershops to Raise Awareness on Prostate Education and Screening 

According to the American Cancer Society*, African American men are twice as likely to develop prostate cancer in their early 50s and twice as likely to die of the disease compared with white men. In an effort to raise community awareness around prostate testing and screening among this demographic, the Community Health Education department at Mount Sinai has partnered with over 10 barbershops in Brooklyn, Harlem, and the Bronx to continue the conversation around the importance of screenings. Physicians from Mount Sinai St. Luke’s and Mount Sinai West provide workshops around prostate health, hypertension, and overall men’s health in an effort to raise awareness, build rapport, and educate the surrounding community.  Since the start of the initiative in 2008, more than 400 men have been tested. 

The Mount Sinai PPS is assisting in the marketing and funding for these barbershop initiatives. 

For more information on these initiatives, please reach out to Marian Y. Scott, MS, Director of Community Health Education, at    



God's Love We Deliver Partners with PPS on Nutritional Meal Delivery Pilot Program 
God’s Love We Deliver (God's Love) is collaborating with Mount Sinai PPS organizations, Mount Sinai St. Luke’s and Mount Sinai Doctors Jackson Heights on a three month meal delivery pilot to provide nutritional meals to high-risk Medicaid patients with diabetes. In line with God's Love belief that “food is medicine, food is love,” the goal of the pilot is to provide nutritional stability, increase comfort, and reduce hospital utilization for participants. More results will be shared and reviewed, once the program ends in December 2018. 


Engaging with Churches and the Community around Early Cancer Screenings  
Mount Sinai's Center for Spirituality and Health has been collaborating with nine churches in East and West Harlem on M.I.C.A.H™ Project HEAL, which stands for The Multi-faith Initiative on Community and Health – Project  HEAL-Health through Early Awareness and Learning. The project provides church leaders known as Community Heal Advisors (CHA) with basic health education curriculum training and health provider resources. Of note the curriculum highlights early screenings related to prostate cancer, cardiovascular health, diabetes, smoking cessation, and mental health. Through DSRIP funding, CHAs have been able to increase its reach across the community and use innovative ways to reach and engage with community members. 


Encouraging Parents to Complete Asthma Medication Administration Form Submission to Reduce Unnecessary ED Admissions
As a part of the effort to reduce avoidable hospitalizations, Mount Sinai PPS is working with partners to educate parents about completing an Asthma Medication Administration Form (MAF) for children with asthma. If the Asthma MAF is not completed, the child is unable to receive his/her medication and may be brought to the emergency department (ED) for treatment.
Forms are accepted on a rolling basis to the school. Mount Sinai PPS partners interested in receiving complimentary posters to educate patients about this important initiative can contact


Reducing unnecessary hospital admissions by bringing care into the community through the Community Paramedicine program 

The Mount Sinai PPS Community Paramedicine (CP) Program provides personalized and coordinated care to patients in their homes. Community paramedics visit the patient at his/her home and communicate in real-time with the patient’s physician over the phone or via video teleconference technology to appropriately treat the patient. The goal of the program is to avoid unnecessary hospital admissions by treating patients in real time at the comfort of their homes. Through DSRIP funding, the program  has expanded to Queens, now making it available 24/7/365 in four boroughs.

Since April 2017, 74% of patients who utilized this service were treated at home and avoided an unnecessary visit to the hospital. We are also excited to announce that in 2018, the Mount Sinai Community Paramedicine Program received 258 patient calls and encounters, surpassing its 2018 goal of 250 calls. Additional 2018 achievements include the following:

  • 18 provider practices and groups in CP program, with over 150 clinicians now on-boarded.
  • New full-time CP operations/program manager was hired to increase support for customers 
  • Only 10% of patients kept at home required an ED visit within three-days of CP encounter.


Person-centered intensive care management intervention for individuals with behavioral health diagnoses

Mount Sinai PPS is supporting CBC IPA to provide a person-centered intensive care management intervention for individuals with behavioral health diagnoses who are identified as being high utilizers of ED and hospital services. Clients will be outreached in the community by program staff and once enrolled will participate in the program for a six month period. A multi-disciplinary team, comprised of a registered nurse, social workers and case managers, will work with the client to provide services tailored to meet their behavioral, medical, and social service needs. Staff members will provide regular in-person contact and 24/7 on call coverage to ensure that clients will have access to care at all times. Recognizing the importance of coordinating care, program staff will work collaboratively with other members of an individual’s care team and support network. 


Educating partners on Health Homes

Mount Sinai PPS is working with six Health Homes to advance awareness and understanding of the Health Home program at both clinical and community organizations throughout its network. 

The PPS is partnering with several other community-based and faith-based organizations to address the unmet needs of our community. Stay tuned as new partnerships are rolled out in 2018.