Team-Based Care
The literature shows team-based care leads to improved outcomes, but as an independent physician we know that can be easier said than done. That's why we've invested in support services for our CIN members. Read on to learn more about care team members available to work with you and your patients to help maximize your CIN performance.
Palliative Care
Consider a specialty-level palliative care referral for patients who meet any of these criteria:
- NYHA class III/IV symptoms with frequent heart failure readmissions
- Anxiety or depression adversely affecting quality of life or ability to make decisions about their illness
- Assistance with decisions making regarding advanced therapies (LVAD, transplant, inotropic therapy)
The Mount Sinai Health System has two practices with identical palliative care services. Please choose the location most convenient for your patient.
Martha Stewart Center for Living
1440 Madison Avenue
212-241-1446
Martha Stewart Center for Living Downtown
10 Union Square East
212-844-1712
Behavioral Health
Patients should be screened for depression using the PHQ-2/PHQ-9 and referred to psychiatric services through their current care pathway depending on their clinic. Individuals with chronic conditions are 2-5 times more likely to have anxiety and depressive disorders compared with the general population, and increased recognition and treatment is essential.
Pharmacy
Pharmacists are key members of the care team who can prescribe/adjust medications in collaboration with the PCP and specialist. They are available to assist with chronic disease management, including heart failure, hypertension, diabetes, and COPD, as well as to do medication reconciliation, adherence, adherence, and polypharmacy counseling. Learn more about available pharmacy services for your patients.
Contact the Ambulatory Pharmacy and Condition Management Team
Certified Diabetes Education Management Team
Certified Diabetes Educators (CDEs) practice at the top of their license. They can help manage patients with both diabetes and heart failure. Patients receive customized education and strategies to achieve an optimal quality of life.