Centers for Medicare and Medicaid Services Recognize Mount Sinai for Personalized Follow-up Care for Medicare Patients

The Centers for Medicare & Medicaid Services has announced Mount Sinai as one of 47 sites awarded admission to a federal program supporting partnerships between hospitals and community-based organizations.

New York
 – January 23, 2013 /Press Release/  –– 

In recognition of a successful program to prevent readmissions, the Centers for Medicare & Medicaid Services (CMS) has announced Mount Sinai, in collaboration with the Institute for Family Health, as one of 47 sites awarded admission to a federal program supporting partnerships between hospitals and community-based organizations. The federal program, called the Community-based Care Transitions Program (CCTP) was created under the Patient Protection and Affordable Care Act. CCTP is aimed at improving patients' transitions between hospitals and post-acute settings, and reducing avoidable hospital readmissions among Medicare beneficiaries.

The Preventable Admissions Care Team (PACT) at The Mount Sinai Hospital is a program where psychosocial drivers of readmission are assessed and addressed through a 35-day social work-led intervention that begins upon discharge.  Through this personalized follow-up care, PACT has been successful in reducing 30-day readmissions by 56 percent and emergency department visits by 51 percent for high-risk patients.

To receive support from CMS, Mount Sinai has significantly expanded the PACT program, which was first launched in 2010, to reach greater numbers of patients and to have a more substantial effect on lowering the overall readmission rates for Medicare patients. To be eligible for CCTP, Mount Sinai partnered with the Institute for Family Health, a Federally Qualified Health Center (FQHC) network that operates 18 health centers in New York State, including the Family Health Center of Harlem. The Institute also sponsors the Harlem Residency in Family Medicine and leads the newly formed Department of Family Medicine and Community Health at Mount Sinai. The two organizations worked together to create the Community-based Preventable Admissions Care Team (C-PACT).

"C-PACT is an innovative collaborative approach to engaging with our patients and bridging gaps in care that will ultimately strengthen hospital-community relationships," said Kenneth L. Davis, MD, CEO and President of The Mount Sinai Medical Center. "We provide care to one of the most affluent as well as one of the most underserved communities in the United States. This program is one example of our continued commitment to addressing the health care disparities presented to us and providing the best care possible to all of our patients."

The C-PACT team will assess the risk of readmission among Medicare inpatients and offer participation in the program to patients at high risk. They will then facilitate closely monitored relationships between those patients and their families with transitional care workers, primary care providers, program volunteers, and a comprehensive range of community-based agencies. High risk patients will receive follow up from the C-PACT team for five weeks following discharge, including phone calls, arranging a primary care visit within 10 days of discharge, home visits and patient accompaniments to facilitate services.

"We very consciously chose the name of this program because it really is a pact between the patient and Mount Sinai," said Jill Kalman, MD, Medical Director of PACT. "We take on the coordination of services, but the patient needs to be willing to do their part as well."

Neil Calman, MD, President and CEO of the Institute for Family Health and Professor and Chair of Mount Sinai's Department of Family Medicine and Community Health said, "The key to keeping people out of the emergency room and the hospital is to ensure that they have a primary care provider and, if needed, a care manager who is available to them at all times. In addition, after obtaining patient consent the Institute and Mount Sinai have immediate electronic access to each other's patient medical records.  This is critical to responding to urgent issues accurately after-hours. We are committed to providing these services to the C-PACT patients."

C-PACT will service approximately 4,800 Medicare beneficiaries annually, many of whom have chronic conditions, low literacy rates, language barriers, limited social support, and other factors which often lead to use of the emergency room instead of primary care for symptom management.

C-PACT will provide increased support to patients by connecting patients and their families to community-based medical services throughout the metropolitan area that are culturally appropriate and readily available to address symptoms that might otherwise result in a 911 call or emergency room visit. C-PACT aims to reduce Mount Sinai's overall, all-cause 30-day readmission rate by 20 percent among Medicare fee-for-service beneficiaries over the first two years of the program.

In addition to the Institute for Family Health, C-PACT's community partners include Visiting Nurse Service of New York, ArchCare at Terrence Cardinal Cooke, Jewish Home Lifecare, Queens Boulevard Extended Care Facility, New York Center for Rehabilitation and Nursing, God's Love We Deliver, New York City Transit Access-A-Ride, and LegalHealth of the New York Legal Assistance Group.

In first establishing PACT in 2010, Mount Sinai's team of nurses, physicians and social workers has bridged gaps in care and strengthened hospital-community relationships in a variety of ways, including improved processes for appointments; expanded visiting nurse services; and outpatients programs and support groups. Social workers identified and addressed the psychological drivers of readmission for patients upon initial discharge. The Mount Sinai team used electronic medical records (EMR) to identify Medicare patients at risk of being readmitted to in the PACT program. The success of PACT and use of EMR as a tool to reduce readmissions also has led to The Mount Sinai Medical Center receiving the 2012 Davies Enterprise HIMSS Award of Excellence , given by the Healthcare Information and Management Systems Society (HIMSS), the nation's leading hospital information technology society.   

About The Mount Sinai Medical Center

The Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai. Established in 1968, the Icahn School of Medicine is one of the leading medical schools in the United States, and is noted for innovation in education, biomedical research, clinical care delivery, and local and global community service. It has more than 3,400 faculty in 32 departments and 14 research institutes, and ranks among the top 20 medical schools both in National Institutes of Health (NIH) funding and by U.S. News & World Report.

The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary- and quaternary-care teaching facility and one of the nation's oldest, largest and most-respected voluntary hospitals. In 2012, U.S. News & World Report ranked The Mount Sinai Hospital 14th on its elite Honor Roll of the nation's top hospitals based on reputation, safety, and other patient-care factors.  Mount Sinai is one of 12 integrated academic medical centers whose medical school ranks among the top 20 in NIH funding and by  U.S. News & World Report and whose hospital is on the U.S. News & World Report Honor Roll.  Nearly 60,000 people were treated at Mount Sinai as inpatients last year, and approximately 560,000 outpatient visits took place. 

For more information, visit http://www.mountsinai.org/
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About the Institute for Family Health
Founded in 1984, the Institute for Family Health is a federally qualified health center network that operates 26 practices in New York State, including eight part time practices that serve the homeless, two school based health centers, and two free clinics. Together these sites serve 85,000 patients who make over 400,000 visits annually.  All centers offer comprehensive primary care and mental health care for children and adults, and many offer dental care as well.  

In 2002, the Institute became the first health center network in the state to implement an electronic health record and practice management system, which now includes a bilingual patient portal. In 2009 all Institute centers received the highest recognition from the National Committee for Quality Assurance as Patient Centered Medical Homes. In addition to health care services, the Institute operates three residency training programs in family medicine, and leads a number of grant-funded programs which focus on reducing racial disparities in health outcomes.

For more information, visit www.institute2000.org.