City Health Works coaches train at Mount Sinai St. Luke’s with Mount Sinai Heart staff.
Partnering with City Health Works, the Care Transitions and Population Health Team at Mount Sinai St. Luke’s and Mount Sinai Heart at Mount Sinai St. Luke’s will soon launch a care transitions pilot program for patients with congestive heart failure (CHF). This program aims to fill a transitional gap in patient care in reinforcement of and education around follow-up care, medications, diet, and exercise.
“After joining meetings with the CHF clinical team, staff identified that many patients needed practical and culturally competent coaching about diet, medications, exercise, and the importance of follow-up care, especially after hospitalization,” explains Theresa Soriano, MD, MPH, Senior Vice President of Care Transitions and Population Health at Mount Sinai St. Luke’s. “A partnership with City Health Works, along with our traditional post-acute partners, fills this gap.”
Founded in 2012, City Health Works—a Mount Sinai Performing Provider System (PPS) Partner—is a Harlem-based organization that trains neighborhood workers to serve as Health Coaches who “motivate individuals to achieve realistic health goals through a holistic approach.” City Health Works’ mission is to “[bridge] the gap between the doctor’s office and the everyday lives of patients diagnosed with life-threatening chronic illnesses.”
“We are thrilled to partner with Mount Sinai and the Heart Program to jointly deliver the best quality care to patients,” said Jamillah Hoy-Rosas, Director of Health Coaching and Clinical Partnership’s at City Health Works. “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.”
Funded through Mount Sinai’s partner dollars, this one-year pilot aims to reach at least 100 eligible patients, identified through specific qualifications. Patients must have a primary diagnosis of CHF during admission to St. Luke’s, be at least 18 years of age, and reside in East, West, or Central Harlem or Washington Heights. These patients must also be recognized by hospital staff as in need of community-based self-management skills training. Each patient will receive individualized health instruction and community-based care coordination from City Health Works Health Coaches, who are trained by nurse specialists from Mount Sinai Heart at Mount Sinai St. Luke’s.
During this pilot, progress will be measured through monthly meetings with the Care Transitions and Population Health team at St. Luke’s, staff at Mount Sinai Heart at St. Luke’s, and City Health Works. With the goal of optimizing patient care outcomes, these meetings will focus on clinical performance, operational workflows, and patient care needs.
This pilot is part of Mount Sinai PPS’s 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 readmissions, increase in compliance with follow-up appointment within seven days to CHF rapid follow-up clinic, complete fulfillment of prescription refill by due date, and adherence with lab/disease monitoring.
This article has been adapted from a previous publication in the Mount Sinai PPS DSRIP Newsletter.