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.


Care Management

MSHP's Care Management Team is a specialized group of nurses, social workers, and care coordinators available to help your patients navigate care, overcome social and economic barriers to health, and improve health literacy. Home Health services are also available. Learn more or refer any patient who could use extra support by calling 212-241-7228 or emailing


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 illnes
  • 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

Martha Stewart Center for Living Downtown
10 Union Square East


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.



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 MSHP Pharmacy 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.


Community Paramedicine

Community Paramedicine offers rapid evaluation and in-home treatment for patients with acute symptoms with the goal of stabilizing the patient at home and preventing ED visits. The response is provided by a paramedic with ED physician oversight and telemedicine support. There is a <60 min response time to anywhere in New York City, 24/7.  We also offer service to Nassau County, Long Island. Relevant diagnostic tools and medications that can be performed/administered in the home setting include:

  • EKG

  • Vital Signs

  • Complete Physical Assessments

  • IV Fluids

  • IV Medications including Lasix, Zofran and more!

  • Pain management

Learn more 

Email Ari Breslauer, MPH, CCEMT-P, Program Director, Community Paramedicine.


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