Patient Bill Regan with, from left: Robin Varghese, MD; Pilar Stevens-Haynes, MD; and Jason
Freeman, MD—members of the coordinated team that treated him on Long Island and in Manhattan.

Even before an official partnership was finalized in December 2018, specialists from the Mount Sinai Health System were collaborating with physicians at South Nassau Communities Hospital to provide advanced and coordinated care to Long Island patients. For 67-year-old Bill Regan, a retired financial services executive from Massapequa, this new relationship proved to be life-saving.

It was in March 2018 that Mr. Regan decided to try a new primary care physician—this time, at South Nassau Primary Care at Bellmore. During his first visit to Carolyne McHyman, DO, Mr. Regan provided the details of his medical history, which included a carotid endarterectomy, a surgical procedure to clear blockages in the carotid artery in the neck, and prescriptions for high blood pressure and high cholesterol. The former long-time smoker told Dr. McHyman that he was “generally in good health,” but when he also mentioned some daytime fatigue and left leg discomfort when he walked long distances, she ordered several diagnostic tests.

They included a chest CT scan, as part of The Mount Sinai Hospital’s Early Detection Lung Cancer Screening program; an ultrasound of the abdominal aorta to check circulation and to rule out an aortic aneurysm, an abnormal bulge in the aorta; a consultation to rule out a sleep disorder; and a recommendation to see his cardiologist, Pilar Stevens-Haynes, MD, for an evaluation.

The CT scan of the lungs, while negative for lung cancer, showed calcification in his aorta. The ultrasound of the abdominal aorta also showed narrowing of the left iliac artery in his pelvis, while a magnetic resonance angiography, which provides detailed images of blood vessels in the body, revealed a 90 percent blockage of that artery. “Honestly, I didn’t worry about my health, but these test results blindsided me,” recalls Mr. Regan.

Meanwhile, Dr. Stevens-Haynes recommended a cardiac catheterization to check for any blockages of his coronary arteries. “Bill didn’t have previous symptoms of chest pain, but coronary artery calcification can be associated with major adverse cardiovascular events, and we needed to get to the bottom of it,” says Dr. Stevens-Haynes.

When Jason Freeman, MD, Director of Interventional Cardiology at South Nassau Communities Hospital, performed the cardiac catheterization on April 24, he discovered that Mr. Regan’s left main and circumflex coronary arteries that supply blood to his heart were significantly blocked and could not be treated with stents, expandable tubes used to open clogged arteries. Now, Mr. Regan would need open-heart surgery—a diagnosis that was made immediately by Robin Varghese, MD, Associate Professor of Cardiovascular Surgery at the Icahn School of Medicine at Mount Sinai, who was at South Nassau that day.

South Nassau’s Center for Cardiovascular Health has long been known for its outstanding care. It is a recipient of Healthgrades’ 2019 Coronary Intervention Excellence Award and five stars for its performance in coronary interventional procedures, placing it among the top 10 percent in the nation; however, it does not perform cardiac surgery.

“When I met with Dr. Varghese, the heart surgeon, I was very anxious, but I came out feeling this is going to be okay,” Mr. Regan says. “He walked me through what the procedure entailed. He had a diagram of the heart and the arteries, and he was positive, calming, and reassuring. He made me feel like ‘we got this and this is what we do every day.’”

Long Island patient Bill Regan was able to receive postoperative care, including cardiac rehabilitation, close to home in South Nassau.

On April 30, Dr. Varghese and his team at The Mount Sinai Hospital performed the three-hour surgery to restore blood flow to Mr. Regan’s heart. “After surgery, we took Bill to our Cardiac Surgery Intensive Care Unit,” says Dr. Varghese, who is also Director of Cardiovascular Critical Care for the Mount Sinai Health System. “He was sitting up in the chair in no time and looking great. He surprised us all.” Within four days, Mr. Regan was released from the hospital and was back home on the South Shore under the supervision of South Nassau’s Homecare program, attending church two days later in Massapequa.

“My entire experience was coordinated and supported by the most wonderful people from South Nassau and Mount Sinai,” says Mr. Regan. “I feel blessed, thankful, and overwhelmed with gratitude to everyone, and I mean everyone, involved in my treatment and recovery at South Nassau and Mount Sinai.”

After he was released from South Nassau’s Homecare program, vascular surgeon Xenophon Xenophontos, MD, performed a successful angioplasty of the left iliac artery. Mr. Regan also participated in South Nassau’s Cardiac Rehabilitation program at South Nassau’s Sports Medicine and Rehabilitation Therapy (SMART) Center in Oceanside, which he completed three months ago. Mr. Regan says he plans to return to the SMART Center this month for additional exercise programs.

Having access to advanced specialty care at The Mount Sinai Hospital while being able to stay close to home for pre- and postoperative care offers many benefits for patients. “Continuity of care is a key component of quality of care, especially when treating patients with multiple conditions,” says Adhi Sharma, MD, Executive Vice President for Clinical and Professional Affairs and Chief Medical Officer at South Nassau. “The care was not only life-saving for Bill, but a seamless journey and patient experience.”

The Transitions of Care Center team includes, from left: Amanda Anderson, MSN, MPA, RN; Claudia Colgan; and Eunice Reynoso, BSN, RN, Clinical Nurse Manager.

When a patient is admitted to a hospital within the Mount Sinai Health System, planning for discharge begins almost immediately to ensure a smooth transition to the next level of care, whether it is at home or at a skilled nursing facility. Studies show that effective discharges lead to improved patient health, reduced readmissions, and decreased health care costs.

Toward that end, the Mount Sinai Health System has established the Transitions of Care Center (TOCC), a centralized telephone-based discharge program staffed by Mount Sinai registered nurses who are specially trained in hospital discharge protocols and are led by a clinical nurse manager.

The TOCC has been tasked with improving patient satisfaction, ensuring patients have access to post-hospital care and are following discharge instructions, and preventing avoidable readmissions. Staff work from a dedicated office on East 16th Street near Union Square in Manhattan, where 11 registered nurses call Mount Sinai patients 24 to 72 hours after they leave the hospital—reviewing and addressing each patient’s unique discharge plan of care.

The Center initially was launched in December 2016 as a pilot program aimed exclusively at patients deemed at high risk for rehospitalization. The program quickly expanded and is now servicing patients regardless of readmission risk or diagnosis who are discharged home from The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West, and Mount Sinai St. Luke’s. In March, the TOCC will add discharged patients from Mount Sinai Brooklyn, with a goal to expand to Mount Sinai Beth Israel in the coming months.

Since the program’s start, nurses have made more than 40,000 phone calls, spoken to nearly 19,000 patients, and provided close to 11,000 interventions to assist patients with post-discharge care needs. “The results have been positive,” says Claudia Colgan, Vice President, Care Coordination, Mount Sinai Health System, and Vice President, Operations, The Mount Sinai Hospital. “In the 12 months leading up to August 2018, patients who were contacted by the TOCC had a 16 percent lower-than-expected readmission rate.”

The Transitions of Care Center nursing staff includes Verisa Robinson BSN, RN, center, and from left: Alla Aminova, BSN, RN; Maki Lahori, BSN, RN; Kristina Davanzo, BSN, RN; Amanda Mendez- Paranavitana, BSN, RN; Connie Fong, BSN, RN; and April Schott-Auerbach MSN, RN, CNL.

While speaking to patients, nurses assess their health status and determine if they are adhering to their discharge care plan. They ensure that patients have filled their prescriptions and are taking their medications properly, that they have the medical equipment they need, and that they are able to attend follow-up appointments. As needed, they perform nursing triage for active symptoms, referring patients  to in- and out-patient providers. They work closely with interdisciplinary care management teams at the hospital where the patient was treated and collaborate with ambulatory teams, home health agencies, and community-based service organizations.

According to TOCC data from January 2017 through November 2018, nurses had 6,290 patient interventions that involved providing educational resources and reinforcing overall discharge instructions, and 1,013 interventions that resolved medication needs. They also helped escalate the management of active symptoms for 825 patients.

“No matter how well the discharge team explains next steps of care, patients often do not fully understand or remember what to do,” says Ms. Colgan. “This is pervasive across the entire patient population, regardless of education or language proficiency or socioeconomic status. At Mount Sinai, we understand that they may be overwhelmed with new directives.”

Mount Sinai is one of the few facilities in the country with a dedicated team of on-staff nurses whose full-time job is to call patients. “Our success lies with our registered nursing team,” says Amanda Anderson, MSN, MPA, RN, Associate Director of Care Transitions for the Mount Sinai Health System. “The TOCC nurses are highly trained by Health System service-line leaders. They understand the Mount Sinai culture of putting patients first, and they collaborate with other hospital staff on the patient’s behalf when necessary.”

“It’s great when we are able to triage and provide a service to someone who really needs it,” says TOCC Senior Nurse April Schott-Auerbach, MSN, RN, CNL. “One of my patients was experiencing increasing shortness of breath and it was clear he needed assistance but was unable to get to an urgent care facility or go back to the emergency room. I was able to triage and collaborate with the Health System Community Paramedicine team, which provided the patient with the more immediate assessment he needed.”

According to Ms. Schott-Auerbach, patients are happy knowing that someone is following up with them. One of her patients told her, “I never had such amazing service from other hospitals. It really makes me feel like Mount Sinai cares about me.”

A team picture: The Transitions of Care team.