Mount Sinai at Home Coordinates and Innovates Home-Based Care
Mount Sinai at Home leaders, from left, Operations Director Alexander Mandl; Albert L. Siu, MD; and Clinical Director Linda V. DeCherrie, MD, Professor of Geriatrics and Palliative Medicine.
The Mount Sinai Health System recently launched Mount Sinai at Home, an innovative enterprise with two key components: a service line of programs across the Health System that care for patients in their own homes, and a research arm, the Institute for Care Innovations at Home.
“Mount Sinai at Home’s programs will align closely with the Health System’s population health strategies and advance our capacity to serve communities beyond our hospitals,” says Director Albert L. Siu, MD, Professor and Chair Emeritus of Geriatrics and Palliative Medicine. Treating patients in familiar and convenient environments can improve communication, coordination, and continuity of care, and reduce the risk of admission and readmission.
“This all started with Mount Sinai Visiting Doctors, which was founded in 1995 and gave us an opportunity to create the Mobile Acute Care Team (MACT),” Dr. Siu says. “When MACT started out in 2014, it was just Hospitalization at Home, but very quickly our teams found more ways to support our patients and our Health System, so we created services such as Rehabilitation at Home for care after hospitalization.” MACT, which was founded with a $9.6 million Health Care Innovation Award from the federal Centers for Medicare and Medicaid Services, has been a success, treating 750 patients so far. Its name presented a challenge, Dr. Siu says, since “MACT was not particularly descriptive from the point of view of patients.” As all of its home-based programs grew, the Health System saw a need to coordinate them and to find a new, unified name.
The result is Mount Sinai at Home, which is also headed by Clinical Director Linda V. DeCherrie, MD, Professor of Geriatrics and Palliative Medicine, who was Director of Mount Sinai Visiting Doctors and Clinical Director of MACT; and Operations Director Alexander Mandl. Mount Sinai at Home will provide “operational, financial, legal, logistical, and clinical” support for home-based care across the Health System, Mr. Mandl says. Its clinical programs are:
- Mount Sinai Visiting Doctors, providing primary care for homebound patients, who are usually very frail and elderly;
- Pediatric Visiting Doctors and Complex Care Program, for young patients, such as children with chronic illnesses or infants who have just left neonatal intensive care;
- Hospitalization at Home, for patients with a condition that might otherwise call for hospitalization, such as acute pneumonia; and
- Rehabilitation at Home, for patients who need care that might otherwise be provided at an inpatient rehabilitation center.
In March 2017, Frederick Ballen became the 500th patient of the Mobile Acute Care Team—now part of Mount Sinai at Home. He was treated at his home in Manhattan by Caitlin Pelan, RN, left, and Joanna Jimenez-Mejia, NP.
These programs will continue to function in collaboration with the Departments of Medicine, Geriatrics and Palliative Medicine, and Pediatrics. Over time, other efforts and collaborations may be added, such as a palliative care program that is now part of a clinical trial led by R. Sean Morrison, MD, the Ellen and Howard C. Katz Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine. In the program, a team of nurses, community health workers, social workers, nurse practitioners, and physicians provide care and support to seriously ill patients at home. “If it is successful, we hope to keep this as a clinical program,” Dr. DeCherrie says. Another study led by Dr. Morrison, on the cost-effectiveness of palliative care, was recently published in the Journal of the American Medical Association Internal Medicine.
Mount Sinai at Home also created a payment model for Hospitalization at Home that in September became the first to be approved by Medicare’s Physician-Focused Payment Model Technical Advisory Committee. “When it is implemented, it will be a model that hospitals around the country can use,” Dr. DeCherrie says.
The Mount Sinai Health System has long been a leader in palliative care, geriatrics, and health care at home. “We already have the largest academic house-call program in the country—Visiting Doctors—and our Hospitalization at Home program is already the largest in the country,” Dr. DeCherrie says. “To put it all together under one service line, that is very different and very new.”
Diane Lieberman, PhD, RD, CSR, CDN, is the nutrition manager at the Mount Sinai Dialysis Center. Prior to working with Mount Sinai, she was the nutrition manager at Rogosin Institute for 21 years. There she managed a staff of dietitians, consulted on research projects, and was responsible for Hemodialysis, Home Hemo coverage, and Peritoneal Dialysis as well as chronic kidney disease and post- transplant patients.
Chernobilsky
Valentine Reed-Johnson RD, CDN, is an outpatient dietitian in the Clinical Nutrition Department at The Mount Sinai Hospital. Previously, she worked inpatient for four years primarily with vascular and general medicine patients. Currently, Ms. Reed-Johnson works with the KPE OB/GYN clinic. She has an interest in Diabetes and Wellness Nutrition. She especially enjoys writing as it is the best way to reach the most people and clear up the overwhelming amount of conflicting Nutrition information in the media.