Esther Moas Pandey, DNP, MS, RN
A nurse finishing up a busy shift at the end of a long week typically breathes a sigh of relief, knowing the next 24 hours will bring a well-deserved day off. It is gratifying to know that a patient who has been on the unit for several weeks will be discharged the next day. But—and especially if the discharge occurs on the nurse’s day off—that satisfaction is mixed with worry for the patient’s health status at home. Many nurses worry about what happens to their patients after they leave the acute care setting.
The health of many individuals, families, and communities is compromised by social determinants of health. Social determinants of health are conditions that influence health outcomes. They are not medical entities, but rather conditions into which a person is born, grows up, lives, and works. Addressing social determinants is the path to improving a population’s health.
Social determinants of health can influence health equity in positive and negative ways—food insecurity, income, housing, access to affordable health services. Social determinants of health can influence health even more than health care or individual lifestyle choices.
Nurses promote quality health care for all and can have a vital role in addressing social and health inequities by implementing social determinants of health screening.
Mount Sinai Health Partners, a clinically integrated network of Mount Sinai’s full-time faculty and community-based providers that sets the Health System’s strategic population health management goals, builds relationships with the population of Mount Sinai patients. Esther Moas Pandey, DNP, MS, RN, has been at Mount Sinai Health System for more than five years and began her career in the Population Health Division at Mount Sinai Health Partners.
“For purposes of population health, we look at utilization. Putting together clinical teams that manage utilization. We assess how our patients are doing—their goals, the need to remove barriers, make a discharge plan. The focus is to get our patients home,” says Dr. Moas Pandey.
Beth Oliver, DNP, RN, FAAN, Chief Nurse Executive at Mount Sinai Health System, recognized this work on population health across Mount Sinai sites, and said, “You need to be on the nursing team!” Dr. Oliver appointed Dr. Moas Pandey as Vice President of Care Transitions for Mount Sinai Health System, putting someone with a storied career into the role. “I started as a visiting nurse. I loved home care. I lived and breathed home care for ten years and this was skilled nursing care, private duty, custodial, and administrative.”
Dr. Moas Pandey was previously Senior Director for post-acute care services. She has more than a decade of experience in post-acute care operations, which are a bridge between care services and rehabilitation for patients to return home following hospitalization. Prior to joining Mount Sinai, she was a Corporate Director at ArchCare and served as Regional Director and Administrator for Premier Home Health Care, Inc.’s private duty and certified home health divisions in New York City. Dr. Moas Pandey holds a Doctor of Nursing Practice degree from Yale University, and a Master of Science from New York University.
Under the guidance of Dr. Oliver, Dr. Moas Pandey and her nursing team assumed leadership of Mount Sinai’s Transitions of Care Center. This centralized telephone-based discharge program is staffed by Mount Sinai registered nurses specially trained in hospital discharge protocols. The Transitions of Care Center’s nurses call Mount Sinai Health System patients 24 to 72 hours after they leave the hospital, reviewing and addressing each patient’s discharge plan of care.
Mount Sinai Health System is one of the few places in the country with a dedicated team of nurses whose full-time work is to call patients to prevent avoidable readmissions. A milestone was reached in April 2022, focusing on transportation and food insecurity. Transitions of Care Center nurses ask patients: “How will you get to your follow-up appointment? Do you need assistance with that?” Nurses ask about food insecurity and access to healthy foods. Registered nurses have the clinical knowledge to discuss specific foods such as a heart-healthy diet and other nutritionally sound meals.
Dr. Oliver has continued to push for a more comprehensive and widespread strategy and says, “We need to do more. We need to put together a social determinants strategy for all nurses across the whole Health System.” Consequently, efforts continue to incorporate social determinants into the daily work of all nurses across every Mount Sinai site.
Dr. Moas Pandey works with nurses to bridge nursing care on the acute side to a patient’s care after they leave the hospital—to make sure patients are successful with their health plan after they leave acute care. “Population health can really speak to the ‘why’ of nursing—to the social justice piece. We know we cannot keep patients at home without addressing their barriers to care and social determinants of health. This is the new rule of nursing.”