Partner Spotlight: Settlement Health 
Health Home Program Update | New Care Coordination Model
Issue #071 | February 21, 2017

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Photo courtesy of NY Department of Health
PPS Mid-Point Assessment with DSRIP Project Approval and Oversight Panel 

The DSRIP Project Approval and Oversight Panel met with PPSs in early February to discuss findings from the Independent Assessor's Mid-Point Assessments of all 25 PPSs in New York State. The Mid-Point Assessments include a review of PPS's progress on project work plans, their funds flow process, quality improvement activities, partner engagements, and others alike. These meetings were open to the public, including a session on January 31st where the public had an opportunity to provide feedback and comments on these findings. To view the recorded sessions, please click here. To read more about Mount Sinai PPS's Mid-Point Assessment, please click here.
Partner Spotlight
 
Federally-qualified health center (FQHC) and community based organization (CBO), Settlement Health, has been providing the East Harlem community with high quality primary care services for over 40 years. Their longevity within the East Harlem neighborhood can be attributed to their community ties and their mission of providing culturally sensitive and accessible primary health care regardless of one's ability to pay.

 
Photo Courtesy of Settlement Health
For as long as Chief Executive Officer, Mali Trilla, can remember collaboration with other community-based organizations has been essential to the success of Settlement Health. Mali said of the different partnerships, "We wouldn't be able to serve  our patients in a comprehensive way if we didn't collaborate with other organizations." In fact, she feels that healing a patient is much more than just providing them with the proper vaccinations and medications, but instead understanding a patient's story and giving them additional resources and services whenever possible.
Settlement Health is committed to expanding services and providing increased access to comprehensive medical services. Their involvement within the Mount Sinai PPS and DSRIP coincides with their plan to enhance services to improve the health of the community.
   
Mali noted, "Our participation with DSRIP provides us the opportunity to share the perspective of a community-based primary care provider with the PPS as it begins to work on the planned transformation of the health care system. We feel DSRIP can offer the opportunity to make improvements that should result in patients having more access to services and better health outcomes."

The Importance of the CBO's Perspective in DSRIP
Photo Courtesy of Settlement Health
Settlement Health is committed to being a part of the effort to change the healthcare system, in part  because they know they bring a unique voice to the PPS. As a FQHC and CBO they can be instrumental in communicating with patients about DSRIP. Mali said, "CBOs have gained the trust and understanding of the people they serve. As a community health center, we have a history of working closely with the community on improving health outcomes and it is important for us to share on how we do this." For over 50 years, the community health center model has utilized data to document that its methods have positively impacted the communities they serve in a patient centered and  cost-effective manner.
 
Settlement Health has been actively collecting data for years. Therefore, when the organization needed to collect data to meet DSRIP measures, they were ready to deliver. Mali said of this process, "We are very focused on quality improvement and are constantly collecting, analyzing and using data to help monitor progress. The reporting and validation of the data is labor-intensive and requires monitoring to ensure that the data is valid and truly reflects what we are doing." 

Photo Courtesy of Settlement Health
Most recently, Settlement Health's data has been available for a 
patient to view within their patient portal. This tool is available in both Spanish and English. Patients are able to view their next appointment, request a prescription refill and more. The patient portal is just one example of a service offered by Settlement Health, an organization where people are respected, treated with dignity, and where there's sensitivity regarding one's language and cultural needs. A consumer health education library is another service offered to patients -  Americorp members are available to assist community residents in their quest for knowledge about medical conditions. Settlement Health also provides outreach and enrollment staff to assist in informing and enrolling community members in eligible insurance plans. This program also connects people to different services including food stamps, food pantries, and more.
 
For more information on Settlement Health, please visit here: http://www.settlementhealth.org/index.html 
To read the full Partner Spotlight Series article, please visit here: http://partner.mountsinai.org/web/mt-sinai-pps/news/partner-spotlight/settlement-health 
Project HighlightsProjectUpdates
Mount Sinai PPS Health Homes for Improved Care Coordination 

Mount Sinai PPS has a network of diverse partners including six  Health Homes that coordinate care for patients through approximately 60 care management agencies (CMAs) within our PPS network. Our six Health Home leads include The Collaborative for Children & Families (effective April 2017), Community Care Management Partners Health Home, Community Healthcare Network Health Home, Coordinated Behavioral Care, Mount Sinai Health Home, and Queens Coordinated Care Partners, LLC.

The New York State Medicaid Health Home Program focuses on providing better care coordination for recipients of active Medicaid with two or more chronic conditions or one qualifying condition (HIV or Serious Mental Illness for adults; HIV, Serious Emotional Disturbance, or Complex Trauma for children). Individuals who fit these criteria are enrolled if they also have a functional need for care management. Health Home leads are responsible for managing a network of CMAs, comprised largely of community-based organizations. Care managers at these CMAs are critical, as they help patients coordinate medical, behavioral health, and community support services. Additionally, Health Home care managers help coordinate the various instructions, services, and resources that patients receive to streamline and make sense of competing, and sometimes complicated, health needs. Essentially, care managers help patients navigate the complexities of their healthcare.

The PPS is working closely with the Health Home leads in our network to socialize the importance of Health Home enrollment across the network. Together, we are working to develop enrollment and referral strategies. We encourage partners to learn more and take advantage of this service.

How do I learn more about Health Homes?
We are in the process of developing Health Home educational materials for partners, so stay tuned for more information!
Care Coordination Cross Functional Workgroup Update: Model of Integrated Care Coordination 

 
Through workgroup meetings and discussions on minimizing care fragmentation and communication gaps across various care teams, the Care Coordination Cross Functional Workgroup recently developed a new interactive model to illustrate ideal integrated care coordination. With this model, a provider type (Mount Sinai PPS partner) would take a lead role depending on the  patient's current needs within the care  continuum. A patient's lead provider type can change based on a  patient's needs or services.   T he care team  at the lead provider provides the care/services to the patient. In this model, the lead provider and its care team would be accountable for the quality, cost and communication of a patient's care. Care  coordination staff either from within the lead care team (if they exist) or from another provider type  that patient receives services from would facilitate care/services across provider types to meet the patient/family caregiver's needs. This care coordination staff would then be responsible for communicating the care plan with the different provider sites from which the patient receives care/services. For more information on this effort, please email Dennis Lumbao at [email protected] .
Project 2.b.viii Update: Community Paramedicine Pilot Program 

MSPPS will be launching its first phase of the Community Paramedicine Program soon! The program seeks to reduce unnecessary Emergency Room visits and hospitalizations by allowing for urgent assessments in the field by paramedics in coordination with emergency and primary care specialists via telemedicine. 
 
The first phase of implementation will begin with clinicians and paramedics that have already received credentialing and training, including the Mount Sinai Visiting Doctor's and MSHS EMS Division personnel.  As the initial infrastructure of the project is implemented, interested partners will be trained on how to integrate Community Paramedicine into their practice. Many MS PPS partners and projects have been introduced to the Community Paramedicine proposal and have expressed interest in pursuing next steps, including:
  • Visiting Nurse Service of New York
  • Institute of Family Health
  • Mount Sinai Cardiovascular Health
  • MSHS BH Crisis Intervention Pilot Phase 1B
  Click here to check out Project 2.b.viii Physician Champion, Dr. Kevin Munjal, provide an overview on what Community Paramedicine is and the benefits of the program. 
The Jewish Board Opens Mental Health Center for Children and their Families 
 
On January 26, the Jewish Board for Family and Children's Services opened up the Brownsville Child Development Center in Brooklyn. This Center is part of the New York City's Early Childhood Mental Health Network operated by the Department of Health and Mental Hygiene. The network launched in July 2016 with the goal of providing new mental health facilities and services to young children and their families. The Center will include a clinic for assessing and treating the mental health needs for children from birth to age five and their parents. The Jewish Board's goal is to create similar programs for children under five and their parents at its 16 mental health clinics across New York City.

The Jewish Board for Family and Children's Services is a site organization under Mount Sinai PPS partner, Coordinated Behavioral Care (CBC). For more information on Coordinated Behavioral Care please see here: http://www.cbcare.org/

To learn more about the Early Childhood Mental Health Network please read here: https://www1.nyc.gov/assets/doh/downloads/pdf/mental/echmh-flyer.pdf

  • Call 1-844-674-7463 to reach our Call Center for assistance on questions about DSRIP & Health Home Eligibility 
  • MSPPS Partner, St. Mary's Healthcare System for Children is hiring. Attend an Open House Session for more information. Click here for more information. 
Mount Sinai PPS | [email protected] |   www.mountsinaipps.org |  1-844-674-7463