Primary Care Practice Redesign Newsletter
Cohort 1 | Issue 4
January 9, 2019
This newsletter is a biweekly forum to keep practices
connected and informed on the Cohort 1 Redesign efforts.
For previous newsletters you may have missed, please visit MSHP's News and Media page .
Update on Redesign Initiatives
We have five project areas that we will roll out in this phase of our Redesign efforts. Your practice facilitators will guide the five project areas below.
Five Projects
  • PI and QI Training
  • Care Wellness Survey
  • Same Day Access
  • Daily Huddles
  • Transitions of Care

We are continuing our focus on huddles. For practices that have daily huddle practices in place, we are deepening this work by adding pre-visit planning and population health management. For practices new to the huddle process, we are clarifying roles, timing, and structure of huddles. As always, the best teachers for this work are other practices, so please feel free to reach out to your other Cohort 1 members. For email details, see Issue 1 of our newsletter.

For any questions about the projects, please reach out to your practice facilitators:
Matt Miesle & Chris Scalamandre : 85th Street and Brooklyn Heights
George Lourentzatos : 23rd Street, Ansonia, Sam Friedman, Williamsburg
Reminder: Next Learning Collaborative
January 25th, 2019
150 East 42nd Street, Fourth Floor
8:30am - 12:00pm
Breakfast will be served at 8:00am
Population Health Management
In the fifth episode of the MSHP podcast series, Dr. Ruchi Tiwari, Director of Pharmacy, Population Health, joins MSHP’s Chief Medical Officer, Dr. Robert Fields, to discuss clinical pharmacy in primary care and ambulatory settings and how clinical pharmacists can be crucial to population health management. Dr. Tiwari sees clinical pharmacists as coaches and champions for patients and key players in the goal of medication adherence.
Also available through iTunes and Google Play
Behind the Scenes with Care Management
What is Care Management?

Patient care at Mount Sinai Health Partners goes far beyond medical visits to the doctor’s office. Our MSHP Care Management team partners with patients, family caregivers, and providers to identify and address known risk factors that can impede health including housing instability, language barriers, medication adherence, and health literacy. Together with community-based and telephonic disease/symptom management and navigation services, the nurses, social workers, and care coordinators of MSHP Care Management blend their skills to offer personalized, impactful support to each referred patient.
Meet Kristin Muzina , LCSW, the Director of Care Management, responsible for servicing employed practices  
How are Patients Identified?

“We mine data looking for patients at high risk for avoidable utilization and work to identify and address their most pressing needs. We like to think of ourselves as the eyes and ears in back of your head. Sometimes providers have ‘blind spots,’ meaning patients attributed to them that they are not even aware of or who are seeing doctors outside of the health system. We help bridge the gaps and most of all want our providers to know that we’re here to assist them in helping take care of their most vulnerable patients.”
– Maria Basso-Lipani , LCSW, Senior Director of Care Management
All attributed patients are eligible for care management services. This means the patients you know, as well as patients you may not be familiar with who are “assigned” to your practice by health plans. Patients are identified as follows:

1. Through a Transitions of Care Initiative covering all patients who are discharged from any hospital.
  • Care Management reaches out to patients to ensure that they have a follow-up doctor’s appointment within 7-14 days post-discharge. They assess barriers to care and prepare the patient to do medication reconciliation with their doctor.
2. Through Analytics to Identify “High Risk/Non-Hospitalized” Patients
  • MSHP, working with Lumeris, gives patients a “care management score” based on their medical and psychosocial complexity. Care Management proactively outreaches to patients with certain scores to identify and address their needs, including ensuring they are seeing their provider
3. Thorough Your Recommendation
  • The team also invites recommendations from practices of patients who need additional support. To recommend a patient, email or call 212-241-7228

How are Providers Notified?
Providers are notified via Epic that their patient is in care management and will receive useful notes and information from care management staff about how they are supporting the patient.
In Your Words
Interview with Dr. Jason Kindt and Molly McNeil
of the
Samuel J. Friedman Health Center for the Performing Arts
You won’t find old magazines in the bright, music-filled waiting room of the Samuel J. Friedman Health Center located in the heart of Times Square. Instead, this health center, a partnership of The Actors Fund and Mount Sinai, displays artwork of performers and stacks of Playbills for its patients—New York City’s entertainment community. In keeping with their commitment to HIV prevention, bowls of condoms are also available.

Just over a year and a half old, the health center has two full-time physicians – one family medicine and one internal medicine/sports medicine physician. “We see lots of dancers and worker’s comp injuries,” said Dr. Jason Kindt, medical director. Because of this, an on-site physical therapist is essential to the practice. A dermatologist and podiatrist also complement the practice and its two Medical Assistants were recently joined by two more MAs and a nurse will be joining shortly to meet the practice’s demands.
Speaking of his patients, Dr. Kindt commented, “I have tremendous admiration for what they do, as it’s a very challenging profession. At any given time, many of them are out of work even with their great talent.” Because they are connected to the Actors Fund, we are able to offer the uninsured subsidized health care. People with no insurance can be seen.” 

It’s not all singing and dancing, though. While the center does indeed treat many singers and dancers, it also takes care of Local 1, the stagehands. Dr. Kindt explained that the Local 1 members are typically men over 60 in a lot of pain with orthopedic issues. Local 1 has a population health agreement with the health center, where they pay a per-member-per-month fee for their members that are seen. They also do not require co-pays as a way to remove barriers to the care they need.
Serving this unique community is of top priority to Molly McNeil, Practice Manager.

This past October, the health center began participating in “Q Reviews,” which delivers text messages surveys to patients immediately after being seen. “We receive reviews in real time and have the highest quality review scores. We can also perform service recovery and address any issues immediately with our patients, said Ms. McNeil.

To assist its members, the Actors Fund offers insurance counseling and also employs 24 social workers co-located in the building who help with everything from HIV counseling to affordable housing to career transition support. Mount Sinai physicians staff monthly on-site Actors Fund seminars on a wide range of health topics, from injury prevention to sexual assault.

Dr. Kindt also commented on the mental health struggles his population faces– the anxiety and panic attacks that affect even the most seasoned performers who don’t know when or if they are going to work again. The Actors Funds assists with finding mental health treatment on a sliding scale basis, but it’s still a process to get patients seen and it would be beneficial to one day offer on-site mental health services.
Speaking about the Primary Care Practice Redesign, Dr. Kindt and Ms. McNeil stated that they were very close to starting daily huddles. Because of staggered start times of the medical assistants and their dual-responsibility of front desk support, it’s been challenging getting huddles started. With the addition of two new medical assistants and an RN starting shortly, the center will be assigning medical assistants to providers and will start each day with a huddle beginning in January 2019.

The staff is proud to be serving the entertainment community and many hold the theater near and dear to their hearts. “If I could play show tunes 24/7 in the waiting room, I would!” said Dr. Kindt.
While the Samuel J. Friedman center addresses the unique needs of the entertainment community, it is also open to everyone, including non-performers. Still new to entertainment industry, the Friedman Health Center is not known to all and The Actors Fund and Mount Sinai are continuing to think of ways to advertise and market the heath center to this very talented and deserving community.   
National Transformation News
Getting Rid of Stupid Stuff
At Dr. Melinda Ashton’s organization, all employees were asked to look at their daily EMR documentation experience and nominate anything that they thought was “poorly designed, unnecessary, or just plain stupid.” “Everything that we might now call stupid was thought to be a good idea at some point,” she commented in a NEJM Perspective piece. Nominations fell into three categories:

  1. Documentation that was never meant to occur and would require little consideration to eliminate or fix;
  2. Documentation that was needed but could be completed in a more efficient or effective way with newer tools or better understanding; and
  3. Documentation that was required but for which clinicians did not understand the requirement or the tools available to them.

According to Dr. Ashton, “We seem to have struck a nerve. It appears that there is stupid stuff all around us, and although many of the nominations we receive aren’t for big changes, the small wins that come from acknowledging and improving our daily work do matter.” 
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If you have any questions please contact Stella Safo, MD, MPH at . Is there a topic you'd like to see covered in a future issue? Reach out to Lisa Bloch at .