Behavioral Health
Individuals with chronic conditions are 2-5 times more likely to have anxiety and depressive disorders compared with the general population. All patients should be screened annually for depression using the PHQ-2/9 and referred to psychiatric services as appropriate.
Patients with chronic medical illness and a comorbid psychiatric diagnosis have poorer quality of life, increased functional disability, and increased mortality. Depression, however, is highly treatable. Screening and intervention are therefore essential aspects of care.
The Mount Sinai Health Partners Behavioral Health Hub has a variety of multimedia resources to help you learn about and manage behavioral health needs in your primary care practice.
Care Management
Mount Sinai Health Partners Care Management social workers and nurses partner with patients, family caregivers, and providers to identify and address known risk factors that can impact patients’ health. The medical complexity inherent in many patients with chronic illnesses requires the involvement of multiple clinicians across many care settings. Interdisciplinary, team-based care may be the most effective approach to chronic disease management and care. Care Management intervention includes:
- A comprehensive assessment of the patient’s understanding of and ability to manage their illness, including a psychosocial assessment
- Development of a comprehensive care plan to set goals to optimize health and quality of life
- Follow-up communication with referring provider
Referral Criteria
May include those with:
- Multiple no-shows
- Unexplained non-adherence to medications, testing, or treatment
- Demonstrated difficulty managing symptoms and/or disease processes (including those newly diagnosed)
- Frequent admissions or ED visits that may be preventable with additional support
- Complex family dynamics that deplete the provider
- Difficulty accessing needed community-based care
- A high “worry score” — patients you, as the provider, are most worried about from visit to visit
Note: MSHP Care Management prioritizes patients in MSSP, ACO REACH and Healthfirst contracts and those patients with Medicaid.
For questions and to refer patients to care management services, please contact 212-241-7228 or email MSHPCMReferral@mountsinai.org. Epic users can also use the MSHP Care Management Referral in Epic (order #391414).
Certified Diabetes Education Management Team
Registered Dietitians (RD) who are Certified Diabetes Care and Education Specialists (CDCESs) practice at the top of their license to serve patients with uncontrolled diabetes, heart failure and/or obesity. They work in a collaborative manner with primary care physicians, endocrinologists, cardiologists, vascular and lower extremity specialists, nephrologists, ophthalmologists and pharmacists to support patients in achieving their optimal state of health and prevent complications relating to diabetes. They provide diabetes self-management education to patients and caregivers so that patients can be true partners in their care.
The RD CDCESs deliver personal nutrition counseling to help patients achieve their optimal weight and state of well-being. The RD CDCESs are embedded in Mount Sinai primary care, specialty care, and multi-specialty practices. Patients receive customized education and strategies to achieve an optimal quality of life. They are also available to provide patients with video visits and telephone consults.
RD CDCES engagement includes:
- Assessing and educating patients and caregivers on their health conditions (diabetes, heart failure and/or obesity)
- Cohesive collaboration with the medical team to integrate evidenced-based care into patient’s plan of care, ongoing monitoring (blood sugar levels, weight, lower extremity swelling and symptoms), and real time support and follow up by the medical team
- Oversight and training by a medical director
- Outcomes evaluation (HgbA1C, BP, weight loss, BMI etc.)
Home Health
- Home Health referrals should be handled through the designated Home Health nurse coordinator, and a member of the care management team through the Care Management referral information below. The Home Health nurse coordinator will assess the patient’s needs and determine appropriateness of Home Health.
- Telephonic education and reinforcement can be also be delivered by the Nurse Clinical Coordinator. (The home health RN will not provide patient interventions, they will refer to nurse care coordinator if needed.)
- Nursing interventions can include various educational components including recognition of high risk symptoms with an action plan, dietary guidelines, medication management, and monitoring of blood glucose, weight, and blood pressure.
How to refer:
- Use the MSHP Care Management Referral in Epic (order #391414)
- Email mshpcmreferral@mountsinai.org
- Call 212-241-7228
Providers who refer patients can expect:
- Prompt and efficient processing of your referral
- Communication about referral processing and assignment through the Epic Inbasket
- Follow up from clinical staff within one week of assignment
Palliative Care
Consider a specialty-level palliative care referral for patients who meet any of these criteria:
- NYHA class III/IV symptoms or EF < 20% with frequent heart failure readmissions
- 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
Pharmacy
Pharmacists are a key part of the care team for chronic disease management including diabetes, heart failure, and COPD. They are credentialed providers that can prescribe and adjust medications through the Collaborative Drug Therapy Management Model. Pharmacists are embedded in primary and specialty care, as well as the Condition Management Program.
Referral Indications
- Uncontrolled chronic diseases, such as hypertension, diabetes, heart failure, asthma, COPD
- Hospital discharge
- High utilization
- Polypharmacy and medication reconciliation
- Medication adherence barriers/challenges
Mount Sinai Medication Access Program (MAP)
The Medication Access Program (MAP) is a telehealth service that offers personalized, one-on-one support to address medication needs. The dedicated and knowledgeable team provides education, counseling, medication home delivery, and financial assistance for eligible patients.