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 firstname.lastname@example.org.
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 email@example.com.
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 firstname.lastname@example.org or 917-903-3691.
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
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 Marian.Scott2@mountsinai.org.
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.