Partner Spotlight Series: The Brooklyn Hospital Center Partner Spotlight Series: The Brooklyn Hospital Center

Partner Spotlight Detail

The Brooklyn Hospital Center

Photo Courtesy of The Brooklyn Hospital Center

The Brooklyn Hospital Center (TBHC) is addressing needs in its diverse community with the help of the Mount Sinai PPS (MSPPS) and DSRIP. With over 360,000 annual patient visits, this community teaching hospital serving Fort Greene, Flatbush-Ditmas Park, Bushwick, Greenpoint, Sunset Park, and Williamsburg, delivers primary, specialty, and behavioral health care, as well as dental services. Founded in 1837, Brooklyn’s first voluntary hospital has evolved and grown significantly to continue meeting the needs of their ever-changing population. To do so, TBHC has committed to aligning with DSRIP efforts to address gaps in care and reduce avoidable hospital admissions. 
With the help of the MSPPS, TBHC has reshaped its workflows, implemented new technology, and collaborated with other MSPPS partners to meet key DSRIP performance measures. 

DSRIP Partnership Encouraged Call Center Expansion and Workflow Redesign

In fact, several MSPPS performance measures align directly with TBHC’s goals to close care gaps for patients with diabetes, hypertension, depression, or behavioral health issues. 

To drive these efforts forward, TBHC expanded its call center to not only receive calls to assist patients and providers, but to also reach out to help patients schedule appointments. The call center staff, which now includes patient navigators, reviews patient lists to identify patients who may not have been seen for a particular needed service. After an appointment has been scheduled, the staff member sends a note to the provider or medical assistant (MA) regarding the missing service. This helps achieve the goal of closing that care gap during the next visit. 

At each ambulatory care site, pre-visit planning reports, run for the next day’s scheduled patients, inform the care team if a patient has diabetes, hypertension, or depression and the last visit date. This report is then discussed at morning huddles to highlight any needed gap closure. Once the patient arrives, the MA reviews the patient’s electronic medical record (EMR) to make sure all appropriate tests and screenings are completed. This workflow was implemented to reduce missed opportunities to close a care gap. “Together, the care team can use data to take action on any open care gaps while the patient is in the office and focus outreach activities on people who have a lapse in routine care,” said Sheila Anane, Director of Innovation for Ambulatory Care Administration. 

Photo Courtesy of The Brooklyn Hospital Center

Photo Courtesy of The Brooklyn Hospital Center

In addition to the call center, TBHC will be implementing Epic as their new EMR beginning this summer. Efforts related to DSRIP and Meaningful Use will be embedded in the EMR. The EMR will allow the practice and call center staff to run reports to support patient outreach efforts, along with automating appointment reminders to targeted patients via phone, text, or email. 

“Quality improvement is needed to promote healthy outcomes and through the PPS we are pushed to strategically think about how to achieve them in different ways,” said Ms. Anane. 

The partnership with MSPPS has encouraged TBHC to consider new ways of providing care. For example, as a part of MSPPS efforts to conduct retinal eye exams onsite, TBHC will be pursuing this effort using onsite retinal eye cameras to make care coordination as patient-centered as possible. 

To support efforts to reduce avoidable hospitalizations and readmissions, TBHC participated in the New York State Department of Health Medicaid Accelerated eXchange (MAX) Series. As a participant, TBHC developed a workflow to support high utilizers, defined as patients who have been hospitalized more than four times in the last twelve months. High utilizers often have a combination of medical, behavioral, and social needs. High utilization is a “symptom” of an unmet, unaddressed/ineffectively addressed, or unidentified need. In January 2017, a multi-disciplinary workgroup was established to develop a workflow to identify eligible patients and create care plans that address unmet needs resulting in reoccurring admissions. In the last year, 297 patients have been identified as high utilizers. The pilot showed a reduction in admissions in the 90 days after becoming high utilizers. Many of the identified needs are social, thus emphasizing the need for partnerships with community based organizations. 

Collaboration with NADAP to Expand Services to Patients

The Brooklyn Hospital Center’s engagement with MSPPS has created opportunities for several community partnerships. In addition to participating in workgroup discussions on DSRIP performance measures, TBHC established a partnership with the National Association on Drug Abuse Problems (NADAP) for Medicaid Health Home (HH) referrals. Since December 2017, a NADAP HH staff person is on-site at TBHC five days a week. The HH staff receives a list of the hospital’s high utilizers and referrals from TBHC house staff, case managers, and social workers. The HH staff will then outreach to the eligible patient and work with them to begin the HH enrollment process. TBHC has had 63 patients enrolled in the NADAP Health Home Program.

The Brooklyn Hospital Center is optimistic for the future with MSPPS. Kaela Fonzi, Project Manager for Marketing and Communications, said, “It’s an exciting opportunity to bear witness to the remarkable shift in the healthcare delivery system. As a hospital, it is our job to adapt to this new model of care, to do the work to educate our patients and move our whole community to a healthier and more vibrant state.”

To learn more about The Brooklyn Hospital Center, read here

To learn more about utilizing these services, please visit here to schedule appointments online or call 833-TBHC-NOW to access the call center for any questions. 


Photo Courtesy of The Brooklyn Hospital Center