MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Alice Cronin

CSTO Montefiore Nyack Hospital

160 N. Midland Avenue





Q2 Please describe your company or organizations overall goals and mission.

Montefiore Nyack Hospital is a 375–bed community acute care medical and surgical hospital, founded in 1895 and affiliated with the Montefiore Health System. Its mission is to provide competent, innovative and accessible emergency and acute care services to the residents of Rockland County and surrounding areas.

Q3 Please indicate which category your organization falls under.

Health Care Provider

Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

With a goal of decreasing unnecessary ED, inpatient visits and readmissions, and improving the rate of enrollment for Health Home eligible patients, Nyack Hospital in collaboration with Rockland Paramedic Services (RPS), has designed and deployed a Community Paramedicine Project. With funding from the Montefiore Hudson Valley Collaborative Innovation Fund, it will improve communication between the ED and first responders, evaluate the need for emergency care, and augment the discharge plan for patients. MHVC also provided technical assistance around sustainability and project design in order to demonstrate a return on investment within the project period. The project (initially) is targeting patients who are high risk, high ED utilizers (defined as those who visited the ED more than 10 times in 2016), are Medicaid or Medicaid HMO and have two or more chronic conditions.

Mobile Health Integration and Community Paramedicine are evidence–based strategies to engage patients in their care and fill healthcare gaps, improve patient outcomes and reduce health care costs. In this innovation model, Nyack Hospital is using technology (Twiage software) to strengthen the line of communication between the paramedic and the Hospital, evaluate the need for emergency care, and to augment the discharge plan for patients. Where possible, Paramedics will make any interventions that can be taken to improve outcomes while potentially keeping the person in their home. They work with Mobile Health Coordinators located at Montefiore Nyack Hospital who provide medical control. Patients identified in the target cohort are flagged on arrival and assessed for engagement by the Nyack Hospital mid–level clinical navigator and ED Social Worker. Prior to discharge the navigator introduces the program and enrolls the patient. A referral to RPS can be initiated either at the time of a 911 call, by the clinical navigator based on a recent visit to the ED, or when post–discharge follow–up is required. RPS´s role is to provide services in the field for post–acute care, post ED care for readmission and transitional care. RPS will make a home visit to assess the patient´s condition and social determinants of health, making referrals through the coordinators as appropriate to both clinical and social services.

The target population for this innovation initiative is the ED High Utilizer population, who is frequently in the Hospital´s ED, utilizing ambulances for transport and requiring inpatient readmissions, and typically overnight when most of the hospital´s resources and referral sources are unavailable and follow–up the next day is challenging. The goal is to identify the underlying cause issues creating this high– use pattern. Clinical data is shared by both Nyack Hospital ED and RPS allowing the clinical navigator to access to the patient´s electronic medical record and the paramedic´s assessment of the situation. Home assessment for the social determinants of health such as housing, lack of family support, financial issues etc. along with clinical interventions can guide intervention to provide the patient with referral to appropriate community supports without transport the ED or hospital admission.

The innovation addressed the six innovation criteria as follows:

  1. Return on Investment
    A decrease in unnecessary ED visits will result in lower systemic healthcare costs in addition to a decrease in penalties for readmissions and a decrease in denials for unnecessary ED visits. A decrease in ambulance use and related costs are anticipated with future reimbursement potential for paramedicine and patient navigation. Additionally, there will be improved staff utilization and satisfaction scores and improved patient outcomes due to a more efficient and seamless system of assessment, deployment and follow–up.
  2. Scalability
    Mobile Integrated Healthcare and Community Paramedicine is a program that with integration to a community ED could provide care to those in urban, suburban or rural parts of the country. It enables appropriate care to patients who have transportation issues, no PCP, live a long distance to the nearest health care agency, etc. Both the Mobile Integrated HealthCare and Community Paramedicine programs are established throughout the US. This initiative appears to be the first to be directly integrated with an ED with the goal of creating a community network in support of patients with chronic conditions and multiple determinants of care.

    This innovation initiative can be expanded throughout the county so that all community–based organizations are part of the referral network as well as the other healthcare facilities in the county. Rockland Paramedics are already involved in a Behavioral Health Response Team that is working on crisis stabilization and use of Twiage, which could potentially allow for psychiatric intervention as the software develops video capabilities and telemedicine capabilities. Additionally, this initiative could be scaled across a large healthcare network, by connecting hospitals to community paramedic programs.
  3. Feasibility
    The innovation has been integrated into the ED Care Triage team, comprised of ED clinical staff, case management, social workers, financial and registration management and IT, that meets every two weeks. In addition, process improvement efforts are utilized throughout the organization drawing on the skill of over 40 employees who are lean trained, some with Six Sigma training as well. Nyack Hospital has partnered with Rockland Paramedic Services (RPS) on this innovation initiative, an organization that has a strong community presence. RPS has received the NYS EMC Council´s Excellence in EMS Quality and Safety Award and the Rockland County Excellence in EMS Quality and Safety Award and has have already demonstrated the desire and ability to branch out beyond just EMS services. The hospital has a close working relationship with the Behavioral Health Response Team with RPS and this is a natural progression to the next phase.
  4. Evidence–based Support for Innovation
    An evidenced–based practice, over 32 states have Community Paramedicine programs. In California, a recent evaluation of a similar program concluded "post–discharge, frequent EMS user, tuberculosis, hospice and behavioral health projects are safe, improve patients´ wellbeing, and in most cases, generate savings for health insurers and hospitals that exceed the cost of operating these projects.";pdf/Second%20update%20to%20public%20report%20on%20CA%20%20CP%20project%20020718.pdf
  5. Relevance to Medicaid Population
    Nyack Hospital is committed to the DSRIP quadruple aim participating in projects with MHVC, with this innovation initiative targeted specifically at Medicaid recipient’s population designed to reduce hospital admissions, ED visits, and to enroll those eligible in health homes. Included in the initiative is assessment for the social determinants of health with referral and warm hand–off to community–based organizations who can provide support and services in a community setting.
  6. Speed to Market
    The innovation project took two weeks to get up and running with five volunteer ambulances on board.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.

Yes (please specify when and the estimated number of people impacted):

The Mobile Integrated HealthCare project at Montefiore Nyack Hospital in conjunction with the Community Paramedicine Program (CPP) for RPS went live on February 1, 2018. To date, Montefiore Nyack Hospital has reached out to not only the High Utilizer (HU) cohort, but also potential High Utilizers as identified by Case Management and the ED staff. 12 of 14 ambulances are using Twiage, the pre–hospital notification system. There have been 31 referrals to the CPP by the hospital, and the program paramedics have been successful in intervening at the patient level preventing a revisit and sending the Behavioral Health Response Team out for a suicidal patient. Out of these referrals 48% to date have not returned to the ED or been admitted to the hospital, effecting a 20% overall decrease in HU visits to the ED as part of this and another aligned project. The team knows most of these patients having cared for them in the ED and so for them it is very satisfying to see them make a difference. They also know their primary care physicians well and are finding it easier to get next day appointments as well as medication prescription refills. Some of the challenges faced are: 1. People cancelling the visit when the paramedics arrive stating all is OK, which has only happened twice. 2. Difficulty engaging non–adherent patients including homeless, and chronic substance abuse patients, both of whom refuse to be assessed and do not want interventions.

Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)


Social and Community Context,

Health and Health Care,

Neighborhood and Environment

Economic Stability

Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared