NEW YORK (September 12, 2017)—City Health Works and Mount Sinai St. Luke’s (MSSL) are collaborating on a one-year pilot, launched in mid-July, to reduce hospital readmissions for patients with congestive heart failure.

The program will provide 100 eligible Medicaid patients in Harlem, Washington Heights and the Upper West Side with individualized health coaching and care, enabling them to self-manage their condition in their homes and, in the process, reduce hospital readmissions, which is a central goal of the New York State Delivery System Reform Incentive Payment Program (DSRIP). Through this collaboration fostered through the Mount Sinai Performing Provider System (MSPPS), nurse specialists from the MSSL Heart Failure Team have trained City Health Works’ health coaches on heart failure and key self-management tools for congestive heart failure patients.

“Many patients need practical and culturally competent coaching about diet, medications, exercise and the importance of follow-up care, especially after hospitalization. A partnership with City Health Works, along with our traditional post-acute partners, fills this gap,” said Theresa Soriano, MD, senior vice president of care transitions and population health at MSSL.

Founded in 2012, City Health Works is a Harlem-based organization that trains neighborhood workers to serve as health coaches who motivate individuals to achieve realistic health goals through a holistic approach. Its mission is to close the gap between the doctor’s office and the everyday lives of patients diagnosed with life-threatening, chronic illnesses.

Jamillah Hoy-Rosas, director of health coaching and clinical partnerships, City Health Works, said, “Our health coaches, hired from the neighborhoods we serve, pride themselves on developing quality, trusting relationships with patients and helping them achieve the best outcomes. We are thrilled to partner with Mount Sinai and the Heart Failure Program at MSSL to jointly deliver the best quality care to patients.”

“The health coaches act, in essence, like a community extension of the care team. They team up with their patients, to remind and empower them about the skills they have been taught, so they can manage their heart conditions on their own when the coaches aren’t there,” said Cathleen Varley, a heart failure nurse practitioner at MSSL, who referred the first patient, Gloria Yanni, into this program in July.

Ms. Yanni, who lives on the Upper West Side, is a 69-year-old cancer survivor with several chronic illnesses and has had nine emergency room admissions for congestive heart failure since January 2017.

Her health coach assigned by City Health Works, Hilda Mejias, has been pleased about Ms. Yanni’s engagement in adopting practical steps to take charge of her own health. Their weekly educational sessions—11 to date—have made a quick impact. In the first two sessions, Ms. Yanni learned the importance of daily weight monitoring and how to measure her total liquid intake accurately.

Ms. Yanni said, “These sessions have been very helpful. I’m glad to be in this program.” Since her participation, she has not been readmitted to the hospital.

According to Ms. Mejias, “The most satisfying result about my interactions with Ms. Yanni is the knowledge that she feels much better. For example, she told me how much the swelling in her stomach, legs and feet have decreased. It's rewarding to hear about the impact of my coaching efforts on her daily life.”

This pilot is part of MSPPS’s strategy to improve patient care transitions and reduce avoidable hospital readmissions by creating meaningful partnerships between hospitals and community and post-acute organizations. Progress will be measured through monthly meetings with the Care Transitions and Population Health and Heart Failure Program teams at MSSL and City Health Works.

“This is just one example of the innovative, unique clinical work we are doing with Medicaid patients through DSRIP,” said Arthur Gianelli, president of MSSL and the MSPPS. “Partnerships with community-based organizations like City Health Works will help us better understand the social issues affecting patients’ health and improve care transition efforts. We look forward to developing similar programs with other organizations to tackle chronic conditions impacting our underserved populations.”

Visit mountsinai.org for more information.