Mount Sinai Health Partners Care Management Program

Mount Sinai Health Partners Care Management Program consists of longitudinal care management programs designed to reduce the number of 30-day readmissions to the hospital. These programs are staffed with social workers and care coordinators who assess the individual needs of patients that are high risk for readmission. During the 4 weeks following discharge, patients are followed closely in the community by their social worker or care coordinator in an effort to improve diet and medication compliance, coordinate patients’ medical care and assist patients in getting to follow up visits. Social workers/care coordinators also address a variety of other social needs including housing, insurance, mental health and substance abuse issues which are thought to be contributing to the individual’s readmissions.