January 27, 2016
5 min read

Mount Sinai Hospital launches program to improve transitions of care for patients with VTE

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Pfizer and Bristol-Myers Squibb have awarded independent 2-year grants to the department of medicine at Icahn School of Medicine at Mount Sinai Hospital for the acceleration of the development and adoption of evidence-based approaches to improve care for patients with venous thromboembolism.

The grant ― the largest ever received for a quality improvement initiative by Icahn’s department of medicine ― will be used to create a new program aimed at successfully transitioning patients with VTE out of the hospital setting and into the outpatient setting. 

HemOnc Today asked Eric Goodman, MD, instructor of medicine in the division of hospital medicine at Icahn School of Medicine at Mount Sinai Hospital, and Ashish Atreja, MD, director of the Sinai AppLab and chief technology innovation and engagement officer in the department of medicine at Mount Sinai Hospital, about the new program.


Question: How did the initiative to improve transitions of care for VTE patients come about?

Goodman: The best place to start is with our experience in taking care of these patients. I am a hospitalist and I take care of patients with VTE in the hospital only, and I worry about them when they leave the hospital for two reasons. One reason is that VTE is a dangerous condition associated with high morbidity and mortality, particularly if there is treatment nonadherence in the postdischarge period. Further, the medications that we give can cause great side effects, such as bleeding and bruising. We worry about these patients and with whom they are going to follow-up. When we were awarded this grant, we knew this gave us the opportunity to develop an innovative strategy to be able to take better care of these patients not only in the hospital, but also in the outpatient setting. Our goal is to be able to integrate information technology tools into traditional care management strategies to try to reach out to these patients in a patient-centric way, so they know that they have someone to stay in touch with. 


Q: What will make this initiative unique?

Goodman: A lot of the care management programs that have been formed in the past are for chronic disease, so this is unique in that it is focused on an acute disease. We are using a lot of lessons we have learned from chronic disease care coordination to try to apply this to an acute disease. This initiative is also a unique combination of an in-person relationship between the social worker care navigator and the patient and an electronic communication interface, and we think this is exciting and new. We also know that, for PE and DVT, the first few weeks out of the hospital are crucial, and we know that the risk for bad things happening is high. So, if we can do a better job keeping track of these patients and make sure they have someone to reach, we are doing them a great service.  

Atreja: This is a perfect example of how technology can converge to make a very meaningful difference at a very high impact point. Using all the tools we know of that are used for chronic care management and bringing them together for this very specific group of patients is quite unique. There are many initiatives for preventing DVT and VTE within the hospital, but there are not many initiatives for quality improvement once they leave the hospital.    


Q: The program includes a cloud-based smartphone app. Can you talk about some of the features of the app? 

Atreja: The app actually builds upon a framework that we have to manage chronic disease at Mount Sinai. We provide customized education to each patient so they know what to eat and why taking their medications is essential. We also provide a means to a secure connection to receive text messages and to telemedicine with their traditional care team. For example, if the patient experiences a side effect or they are not able to get their medication because of insurance reasons, then this information is not lost and the information is communicated back to the physician team. Although this is an app for the patient, it actually creates a population health dashboard for the foundations of care team. So, Dr. Goodman and his team can actually see how many patients with VTE they discharge within 1 year, and they can observe what these patients are experiencing now. This population health perspective gives us much more confidence in knowing whether a patient is on the right track.

Goodman: Not only can we see what is happening to the population of patients as a whole but we can also find and reach out to patients who are at risk for complications. We see if they haven’t logged their medications or if they haven’t gone to their doctor, and we can reach out to them and make sure that they are OK. The app offers a very individualized tool from patient to patient, as well as a population tool to keep track of the whole cohort of patients.          


Q:  What is the timeline for launch of this program?

Goodman: We are currently in the planning process. Our goal is to launch sometime in the spring of this year, and we will continue the study through 2017.


Q:  How exactly will the program work? 

 Goodman: When a patient treated in the hospital is diagnosed with an acute DVT or PE, and they agree to enroll in the study, our social worker ― who we are calling our patient care navigator ― will go and meet the patient at the bedside. We think this face-to-face encounter is valuable, as it lets them know there is someone there to help them. The social worker will help them download the app. After discharge, this care navigator will be available to the patient by telephone and electronically via the app to help them if any questions arise. Our study team will keep an eye on enrolled patients by monitoring their input into the app, and we will reach out to patients who do not touch base with us as expected. For some higher-risk patients, we will provide other more intensive care management. We are encouraging patients to be in regular communication with their health care provider, but we are here to support them through the process and to make sure no one falls off the map.


Q: What are the anticipated benefits? 

Goodman: One of the biggest benefits that patients are going to see is that we can help them with a lot of the nonmedical things that often interfere with care, such as issues with prior authorization for a prescription or a pharmacy not having their medication in stock. We also will give gentle reminders regarding follow-up with the outpatient care team, and will work to improve patient engagement and awareness of their VTE.  We hope this initiative will reduce the number of patients having to come back to the hospital because of bleeding complications or a recurrent VTE. Hopefully we will help people improve their medication adherence and access to follow-up care. We want to do the best for our patients every time, and this means being there for them at all times, not just in the hospital setting.  

Atreja: Ultimately, if the patients are on the right path, they will have better outcomes. We are hoping we can demonstrate some of this by making sure they are adhering to medications, by knowing about any complications early on so we can intervene early on. This is a broader philosophy where no patient gets left behind. The best-practice care extends beyond the hospital and into their homes. 


Q:  Do you have any final thoughts?

Atreja: The entire app and platform is developed by our in-house team in the Sinai AppLab and it is a valuable compliance app platform. We are unique in that we have a whole innovation team at Mount Sinai, and I think it is great to see partnership evolving and see endeavors created from this.  

Goodman: From the perspective of a hospitalist, we are always trying to take better care of our patients after they leave the hospital and not just while they are in the hospital setting. This program nicely aligns with everything we are trying to do for our patients. – by Jennifer Southall


For more information:

Ashish Atreja, MD, and Eric Goodman, MD, can be reached at The Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY 10029-6574.


Disclosure: Atreja and Goodman report no relevant financial disclosures.