MSHP Care Management
The Care Management Team works with patients and care givers to address social determinants of health.
Care Management Services
MSHP’s Care Management social workers and care coordinators identify and address the psychosocial drivers of utilization, with a focus on reducing 30-day readmissions among high-risk patients. Through the integration of nurse clinical coordinators, we also offer disease management for certain disease states.
Interventions are delivered telephonically and through community-based encounters, such as medical appointment accompaniment and home visits, as needed. MSHP Care Management will be live onsite at select practices beginning in the spring of 2025.
Referrals to MSHP Care Management are primarily accepted via Epic order for patients with select health plans.
MSHP’s voluntary (community-based) providers can refer patients with behavioral health needs to Care Management by emailing MSHPCMReferrals@mountsinai.org.
For questions, please contact Maria Basso Lipani, LCSW at maria.bassolipani@mountsinai.org.
Maria Basso-Lipani, MSW, LCSW
Vice President
Care Management, Population Health
Judith Dobrof, DSW, LCSW
Director
Care Management
In the Literature
MSHP Care Management is an offshoot of the former PACT (Preventable Admissions Care Team) Program developed at The Mount Sinai Hospital in 2010 to reduce 30-day readmissions among high risk patients.
The Preventable Admissions Care Team (PACT): A Social Work-Led Model of Transitional Care