September 6, 2018
Mount Sinai Health Partners
Clinically Integrated Network Newsletter
Episodes 2 and 3 on Population Health and Care Management 
Each month, we will feature at least one member from our senior leadership team to talk to you about a range of topics including policy and health care news to updates about clinical programs. E-mail us at if you are interested in hearing about a specific topic.  

How does the complex relationship between physician, patients, and health plans create an environment where traditional laws of supply and demand don’t apply? And what does that mean for population health? According to Niyum Gandhi, Executive Vice President and Chief Population Health Officer at Mount Sinai Health System, this is an opportunity to own the problem and solve it by transforming care delivery into a model where both patients and providers benefit from positive outcomes and preventive medicine. 

MSHP’s Senior Director of Care Management, Maria Basso Lipani, LCSW, discusses the Mount Sinai approach to care management, different from case management, in its broad approach to understanding readmission risks and helping patients solve problems by understanding their deeper causes. This approach is based on the principles that the highest-risk patients can be reached, patient engagement is critical, and community collaboration is fundamental. 

Also available through iTunes and Google Play
Key Announcements
Friday, September 28, 2018: Mandatory 2018 CIN Program Requirements Due
Getting Patients to Consent to Data Sharing

It is important to inform your patients that sharing their medical information is secure and is limited only to the healthcare providers involved in their care and the organizations that the patient chooses to give their consent to. Be sure to share this information at the front desk or speak with your patients about this important initiative.  

Key Points to Emphasize When Discussing Healthix Consent with Your Patients: 
  • Faster, informed, and appropriate decisions are possible with Healthix. In case of an emergency, all attending clinicians will have access to the data they need to make the right medical decisions on your behalf. 
  • You will receive safer and more efficient care. With a comprehensive view of your medical history including lab results and allergies, Healthix reduces repeated tests and minimizes the possibilities of adverse drug affects. 
  • A variety of consent options keep you in control of your information and who can access it. You may also withdraw consent at any time. 

The New York State Department of Health has developed patient consent forms is multiple languages that you can use. Click here to access these forms or you can find them under our Forms and Guide section after logging into the MSHP provider portal
Clinical Integration Program Tips and Resources
To fulfill the mandatory 2018 Clinical Integration Program Requirements, you may need to a complete a few videos or PowerPoint modules on Mount Sinai’s Clinical Integration Learning Center (CILC), which is available through PEAK, Mount Sinai’s education portal. 
How to access the Clinical Integration Learning Center (CILC): 
 1.  Log into with your network credentials. This will take you to the PEAK home page. 
2.  Click on “CILC” at the top right corner of the PEAK home page. 
3.  Scroll to the middle of the screen and click on the Mount Sinai Health Partners block. 
4.  On this next screen, click on the pink “Learning Events” link and you’ll be able to access all of our courses. 
5.  Click “Launch Course” for the respective course and you’re all set!

For more detailed instructions on how to access CILC, click here
2018 CIN Program Requirements:
You may have heard from your department/division leadership regarding your outstanding requirements. If you have questions about your CIN requirements, please call 877-234-6667.
  • Care Coordination (First year providers only): Sign MSHP PCP-specialist compact describing a framework for better communication and safe transition of care between primary care and specialty providers. Please access the MSHP Care Compact Attestation via CILC, which you can access from PEAK.
  • Program Engagement (First year providers only): Providers must complete the following tasks: View on CILC through PEAK and attest completion for the following courses on the Clinical Integration Learning Center: Clinical Integration 101, Clinical Integration 201, and Clinical Documentation Quality Improvement (CDQI).
  • Program Education (Primary Care Physicians only): Attend your quarterly on-site population health meetings. 
  • Privacy Training: Complete the Mount Sinai Health Partners online 2018 Health Insurance Portability and Accountability Act (HIPAA) privacy training module on CILC through PEAK.
Population Health in the Literature
Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries

An observational study of over 18 million Medicare discharges examined the association of transitional care management services (TCM), identified through TCM billing codes, with post-discharge outcomes. Seven percent of eligible patients had TCM codes billed following discharge in 2015. These patients had lower rates of mortality and lower total cost of care compared to patients who did not receive TCM billed services. Check out the article in JAMA Internal Medicine .
Quality Corner
What are transitional care management (TCM) services? 

TCM, as defined by CMS, are services rendered post-discharge that help reduce medication errors and promote safe transitions out of the hospital. They include both telephonic outreach and face-to-face encounters. TCM services are eligible for enhanced reimbursement from Medicare, Medicare Advantage, Medicaid and Commercial payers. Learn more
If you have any questions about any of our announcements, please email Mount Sinai Health Partners at or call us at 877-234-6667.  
Contact Us
P: 877-234-6667
F: 212-523-5775