Evidence-Based Diabetes Management
October 2014
Volume 20
Issue SP13

Coalition Invites Mount Sinai ACO to Share What It's Learned About Improving Diabetes Outcomes


If the term “chief happiness officer” starts to work its way across the healthcare landscape, give credit to Jeffrey Farber, MD, MBA, chief medical officer at Mount Sinai Care LLC.

Farber shared that phrase with a group of fellow healthcare leaders to describe how he met the needs of a diverse group of 280 primary care physicians. These physicians work in 26 practices that make up Mount Sinai Care, an accountable care organization (ACO) that formed in 2012 and expanded this year with the addition of the Beth Israel, St. Luke’s, and Roosevelt practices.

In 2010, the Affordable Care Act created ACOs, which pursue the so-called “triple aim” of improved health for populations, better patient experiences, and lower cost of care. Earlier this year, The American Journal of Managed Care created the ACO and Emerging Healthcare Delivery Coalition, which now includes 100 stakeholders from across the healthcare spectrum. The Coalition gives groups like Mount Sinai Care a chance both to share what is working and to learn from others, as these new entities proceed in a changing landscape that measures healthcare outcomes in a different way, and in some cases connects reimbursement with those outcomes.

The ACO Coalition involves payers, providers, ACOs, integrated delivery networks (IDNs), pharmaceutical manufacturers, and specialty and retail pharmacy representatives, among other organizations. Coalition members are engaged in transitioning from a fee-for-service reimbursement model to one that rewards value.

In a Web-based meeting on August 18, 2014, Farber described Mount Sinai Medical Center’s Diabetes Alliance, a management collaboration of the Mount Sinai ACO and the Mount Sinai Health Network. This initiative was designed to improve diabetes outcomes, which Farber said matters, because diabetes care is in the first group of measurements that the federal government tracks for Medicare reimbursement.

Farber walked a group of participants through Mount Sinai’s new process for deploying care coordinators and diabetes educators into practices, to not only identify at-risk patients but to get them to change their behavior.

At its core, Mount Sinai’s model involves transferring the relationship a doctor has built with a patient over to a certified diabetes educator (CDE). CDEs have more time to do the low-key follow-up and training in areas like nutrition, exercise, or social service interventions that are preventing progress. Connecting the CDEs to patients is the job of 24 care coordinators, who have 500 care “encounters” with at-risk patients per week. Patients receive customized treatment plans with a goal of avoiding unnecessary hospital admissions.

The approach is as much art as science. “Our care coordination model is nonclinical,” he said. The coordinators are social workers, not nurses. Their job is to target patients whose numbers or history show they need contact with a CDE, who have both clinical and motivational training. Farber described the approach as “a lot of high touch, not necessarily high tech.”

In 2 of the basic clinical indicators of diabetes—glycated hemoglobin (A1C) and cholesterol—clinics where the intervention has occurred started out with health measurements that were worse than New York City averages, to allow them to surpass city averages. Blood pressure measurements in the clinics have improved, too. Almost half the targeted patients have lost weight (46%), and more patients who should lose weight are self-monitoring—78% compared with 66% before the intervention.

What makes it work? “The pre-implementation meeting is critical,” Farber said. Mount Sinai wants to be certain that primary care physicians understand the role of the CDE and embrace the care coordinator concept. After that, it helps when doctors see their patients improve.”

Farber’s presentation was one of 3 at the session. More presentations and hands-on workshops will take place October 16-17, 2014, in Miami, when the ACO Coalition presents a live meeting featuring keynote speaker Thomas Graf, MD, chief medical officer for Population Health and Longitudinal Care Service Lines, Geisinger Health System.

As ACOs and other emerging delivery and payment models evolve and move away from traditional fee-for-service system models toward cost-effective and value-based care, the need to understand how these models will evolve is critical to building long-term strategic solutions. The mission of the Coalition is to bring together a diverse group of key stakeholders, including ACO providers and leaders, payers, IDNs, specialty pharmacy, and pharmaceutical manufacturers to work collaboratively to build value and improve the quality and overall outcomes of patient care. Coalition members share ideas and best practices through live meetings, Web-based interactive sessions, and conference calls.

Two distinguishing features are the Coalition’s access to leading experts, and its small workshops that allow creative problem-solving.

To learn more or register for the Miami meeting of the ACO and Emerging Healthcare Delivery Coalition, visit

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