Caring for people is a team sport

Helping patients maintain, manage, and improve their health extends far beyond the office consult. Mount Sinai Health Partners offers programs and resources rooted in team-based care to help you and your patients access support for better health outcomes.

We're here to support you and your patients. Where should we start? 

What's New

Transitions of Care

Notifications, Admissions & Discharges

Sign up for the Subscription Notification Management Tool

Know when your attributed patients are admitted or discharged from the hospital and receive HIPAA-compliant discharge summaries with subscription notifications sent directly to you via Epic direct message, email and/or text message 

In the tool you can: 
•    Select the notifications you want to receive - inpatient/ED alert notifications and/or discharge summaries
•    Choose to have the notification alerts sent directly to you via EMR direct message, email and/or text message
•    Add and remove care team members from your practice to receive inpatient/ED alert notifications and/or discharge summaries

Sign up today!

1.    Log on to the MSHP Provider Portal
2.    Select the Subscription Notification Management tile
3.    Complete the required fields

Need help?

Visit the Training Resources Center (log in required)
Contact your Provider Engagement Manager or email us at MSHP@mountsinai.org

Discharge Planning

Help your patients at the time of transition of care from a variety of hospital settings.

Transitional Care Management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making. TCM services include all services provided to a patient at the time of transition of care from a variety of hospital settings. Depending on the medical complexity of the patient, an office visit is required within 7 or 14 days of discharge from the hospital setting.

Learn more: Download the TCM brochure

To facilitate documentation in Epic, utilize the smartphrase: "tcmprovider" 

Care Management

Support patients with risk factors

Refer your patients to MSHP Care Management Services and Home Health Care Services for personalized support and care.

MSHP Care Management Services

We're a team of nurses, social workers, and care coordinators ready to support your patients and their caregivers by helping remove barriers that can impede a patient’s health. We offer the following services: 

• Help your patients understand their care plan and follow medication adherence
• Conduct phone outreach to your high-risk patients, including the elderly and disabled
• Ensure your patients make their doctor appointments and follow-up appointments
• Address lifestyle risks your patients' experience: food and/or housing insecurity
• Provide transportation support

Make a Patient Referral

Email the MSHP Care Management Team at MSHPCMReferral@mountsinai.org or call 212-241-7228. In your message, please indicate the patient's name, date of birth, and service requested.

Learn more

Visit us online and download this flyer 

MSHP Home Health Care Services

Our specialized team of nurses understand the nuances of home health, including benefit design, and are here to offer you support in both evaluating and setting up your patients with appropriate and affordable services in their homes. We offer the following services: 

• Evaluate and set up your patient with affordable and appropriate community services
• Coordinate PT/OT/Speech Therapy in the patient's home
• Set up nursing services in the home
• Support with disease management
• Assistance with daily living activities

Make a Patient Referral

Email the MSHP Home Health Care Team at MSPACCHomeHealth@mountsinai.org. Please indicate the patient's name, date of birth, and service requested.

Learn more

Visit us on the web and download this flyer

Chronic Disease

Remote Patient Monitoring Program

Connect your patients with Connected Hearts to closely monitor your patients with hypertension and/or heart failure.

Connected Hearts, Mount Sinai's remote patient monitoring program allows your patients to monitor their blood pressure from the comfort and privacy of their own homes. Mount Sinai Health Partners' dedicated team of clinical pharmacists is responsible for the day-to-day management of the program and coordination with physicians to intervene as necessary.

Enroll your patients with hypertension and/or heart failure 

(uncontrolled or previously uncontrolled):

Refer patients via EPIC referral order 'condition management' to initiate the enrollment process with the program navigator. Do let us know if you have communicated with the patient about the program. 

Learn more

•    Download this quick guide 
•    View Frequently Asked Questions 
•    Questions? Email the MSHP Pharmacy Team: MSHP.Pharmacy@mountsinai.org

PharmD Chronic Care Management Program

Refer your patients to the MSHP PharmD Chronic Care Management Program

Having a chronic illness can feel overwhelming for your patients. The Mount Sinai Health Partners PharmD Chronic Care Management Program can help. Our clinical pharmacists coordinate chronic care services for  Medicare patients living with two or more chronic conditions, helping them understand how to manage their conditions and medications.

Learn more

Download this quick guide

Make a Patient Referral

•    Refer patients via EPIC referral order "Consult to Pharmacy" or EPIC In-basket message
•    Include CCM referral discussion in the message

Questions?

Email the MSHP Pharmacy Team at MSHP.Pharmacy@mountsinai.org

Prescription Costs

Prescribe lower-cost medications with Real-Time Prescription Benefits in Epic

With Real-Time Prescription Benefits in Epic, you can easily prescribe lower-cost medications under your patient's prescription drug benefit, which can improve medication adherence, lower prescription drug costs, and minimize your patient’s out-of-pocket costs. Patients will know the cost of medications before they ever leave your office.

Get started today! Epic Workflow Details

Real-Time Prescription Benefits is available in Epic in the "shopping cart" after a medication order has been placed. You will see the option to click "Estimate" in the pop-up window. This will display the patient's copay based on the patient's Pharmacy Benefits. Along with the copay, there may be alternative medications that may be suggested by the Pharmacy Benefits Managers (CenterX and Surescript) along with the alternative medication's price.

Learn more

1.    Download this Epic Tip Sheet and follow the instructions
Remember to:
2.    Use the "Estimate Button" during the order entry
3.    If the costs and alternatives do not load, verify, and update the patient's Pharmacy Benefits, NOT medical benefit coverage. To verify in Epic, go into the "Rooming" tab and access the "Verify RX Benefits" section

Questions?

Email the MSHP Pharmacy Team at MSHP.Pharmacy@mountsinai.org

Chronic Condition Management Hub

The Mount Sinai Chronic Condition Management Hub is a centralized resource collection to help you manage patients with chronic conditions. You’ll find quick reference and in-depth, evidence-based guidelines, patient materials, CME events and more.

Visit the Hub to access: 

• Mount Sinai Ambulatory Care Pathways

• Team-Based Care Services

• Patient Education Materials

• CME Event information and more

Mount Sinai Community Paramedicine Program

The Mount Sinai Community Paramedicine Program offers rapid, urgent evaluation and in-home treatment for your patients with acute symptoms.

• 30-60 Minute Response

• Expanded Physical Assessment

• Video Conference with Patient

• Advanced Diagnostics (12-LEAD ECG / Pulse OX / BGL / TEMP)

Advanced Treatment

• IV Fluids, IV LASIX, IV Dextrose

• Albuterol + Steroids

• Pain Management 

Access Through the Transfer Center

1-800-TO-SINAI
1-800-867-4624 Option 2
 

General Resources

Mount Sinai Now 

Mount Sinai telehealth services makes it easy for patients to find the care they need at home and on the go. Patients can use a phone, tablet, or computer to connect with a Mount Sinai doctor through online consultation, video visit, or text—all from the convenience of their home.

Learn more. 

Inform your patients of this service. Share these flyers with them.

• Mount Sinai Now (English)
• Mount Sinai Now (Spanish)

Daily Team Huddle

Daily Team Huddles are short daily meetings where the care team reviews patient visits for the day. Huddles allow for better planning, more efficient patient visits, better quality care, and improve team building. 

Hear from your colleagues on best practices they use to implement Daily Team Huddles in their practice - Watch the Efficient Team Huddles Video