"Mount Sinai Harnesses Community Workers To Lower Heart Patient Readmissions" - Steven Ross Johnson
Mount Sinai Health System's St. Luke's Hospital has been looking for a way to decrease readmissions among its recently discharged heart failure Medicaid patients. With a growing Medicaid patient population in New York's Harlem neighborhood coupled with a system wide push to incorporate more population health strategies within its clinical settings led to a search for a better way to help heart failure patients manage their conditions outside of the hospital. "It was a good and important time to make sure that we were integrating some of these social need interventions as well as connection to the community in really trying to address root causes," said Theresa Soriano, MD, the senior vice president of care transitions and population health at Mount Sinai St. Luke’s. That was the impetus behind St. Luke's pilot program launched in July aimed at reducing hospital readmissions among Medicaid beneficiaries with congestive heart failure by educating patients how to better self-manage their conditions at home. The one-year initiative is a collaborative effort between Mount Sinai and City Health Works, a Harlem-based not-for-profit organization started in 2012 that trains community members to be health coaches. Coaches meet patients at their homes or within the community and work with clinicians on care plans.
- Theresa Soriano, MD, Professor, Medicine, General Internal Medicine, Associate Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Senior Vice President, Care Transitions and Population Health, Mount Sinai St. Luke’s
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