How Mount Sinai is trying to mend “staggering disconnect” with patients

Knowing something is failing is the first step to turning things around. At Mayo Clinic’s annual Transform conference designed to shake up old mores in healthcare, an experience of a patient at Mount Sinai Health System’s East Harlem clinic revealed a broken system. Now efforts are underway to overhaul it.

Mrs. M. was a mystery to Dr. Stella Safo, a Mount Sinai physician. An older patient who had a complex medical history, she saw Safo regularly for a few years, then disappeared from the system.

An electronic notice about scheduling a flu shot prompted Safo to try to contact Mrs. M., to no avail. An organization called City Health Works dispatched a community health worker to find her and determine what went wrong. As it turns out, there was plenty.

Her husband had died six months earlier and Mrs. M. was very depressed. She had a foot infection due to uncontrolled diabetes and had visited the emergency room at a different hospital several times rather than return to the Mount Sinai clinic, even though she got along well with Mount Sinai’s Safo. She had also developed a hoarding problem, a sign of mental illness.

Why did Mrs M. choose the ER at a different hospital and not return to Safo?

Mount Sinai’s telephone appointment system was difficult to use, and Mrs. M. could barely get through. She was frustrated at having had five primary care physicians there in four years. She needed to visit the clinic in person to make an appointment, but had mobility issues that made it challenging.

When she did get in, Mrs. M. had only 15 minutes with Safo, not enough time to address her concerns, and felt she was not being heard. Once she went home, she often forgot the doctor’s instructions.

The problem was not with Safo or with Mrs. M., but with a system that has a “staggering disconnect” with some of the people who need it most,  said Dr. Prabhjot Singh, vice chairman of medicine for population health and director of Mount Sinai’s Arnhold Institute for Global Health at the Mayo conference in Rochester Minnesota.

Singh also serves as founding strategic advisor to City Health Works, which is developing a scalable, neighborhood-based management system for high-need, high-cost patients.

Singh and others from Mount Sinai and City Health Works described to conference attendees how the system failed Mrs. M. and the challenges of making that system work for high-risk, chronically ill patients like her.

Here’s some of what was unearthed: Mount Sinai changed electronic health record systems in 2015, and didn’t convert some earlier medical records, so Safo,who is also program manager for systems design at the Arnhold Institute for Global Health, could not see that Mrs. M. had had a series of ER visits and a hospitalization at Mount Sinai in 2014. Her 2016 visits to the other hospital’s ER were not communicated to Mount Sinai.

Having a health coach from the neighborhood cultivate a relationship with Mrs. M. gave Mount Sinai valuable insights that the system is not designed to capture, said Natalie Privett, lead systems design engineer at Mount Sinai Health Partners, in an interview.

Now, Mount Sinai is redesigning its primary care system to work better for all patients, particularly those with the highest needs, she added. Part of the challenge is identifying which patients need relationships like the one Mrs. M. has with her health coach, Singh told attendees.

“Now we have the knowledge and humility to know that the answer is out there and that the neighborhood holds the keys,” he said. “We’re just starting.”

In Mrs. M.’s case, the health coach from City Health Works, Leny Rivera, reports regularly to her doctor, Safo so she will know what to focus on in their limited time together in the clinic.

City Health Works employs nine community health coaches, who each work with 40 patients at a time. In three years, it has served 400 patients in New York and New Jersey health systems that are working to improve outcomes among large numbers of high-risk Medicare and Medicaid patients, said City Health Works executive director Manmeet Kaur, in an interview.

City Health Works is just one avenue that Mount Sinai is using to change the way it works with high-risk patients, and has already had an enormous impact, Singh added in an interview. He predicted that Mount Sinai’s patient-care system will look and feel different in the next 12 months to three years based on current efforts.

“We’re listening, learning, and we learn by doing,” Singh said. “We fail and figure out how to walk forward.”

This one case study highlights the importance of collaboration between health systems and community organizations. Rivera believes that organizations like hers — City Health Works — can change the way that people in her community think about their health.

“I would like for hospitals to go into the community and better understand what people are going through,” she told conference attendees. “Teach people how to move little by little, from one step to another, make lifestyle changes.”

Photo: Big Changes Ahead from BigStock Photo