The 2014 Healthcare Informatics Innovator Awards: Co-Second Place Winner: Maimonides Medical Center

May 21, 2015
Maimonides Medical Center tied for second place in this year's Healthcare Informatics Innovator Awards Program by leading a consortium of approximately 50 medical, mental health, and social service organizations, payers, and a labor union, to create a "mental health home" for seriously mental ill patients.

Where does care coordination live? To find out, take the D train from Midtown Manhattan to the Fort Hamilton Parkway stop in Brooklyn, walk a few blocks down the area’s main strip, past a sparse array of nondescript storefronts, and eventually, you’ll run into the unassuming facade of Maimonides Medical Center.

It’s there, within the confines of a large, 706-bed academic medical center, which from the outside blends into the southwest Brooklyn landscape, that the concepts of care coordination are alive and well. It’s there that leadership has undertaken a large, collaborative project delivering coordinated care services for seriously mentally ill (SMI) populations—a notoriously hard area for healthcare providers to crack in terms of cost and care.

Maimonides is using complex, integrated technology to virtually co-locate members of a SMI patients’ care team, embedding an electronic alert when a patient event occurs (such as an emergency room admittance). The organization has brought together a consortium of approximately 50 medical, mental health, and social service organizations, payers, and a labor union, to create a “mental health home” for these SMI patients, who typically are on Medicaid and have schizophrenia, schizoaffective disorder, bipolar disorder, or severe depression. Bringing together members of a care team, in its own right, is no easy task. Doing it for SMI patients, who often have co-morbidities, lack engagement with their primary care physician (if they even have one to begin with), and experience higher rates of ER admission than the general population, poses a herculean challenge.

“We know they have the complex medical issues because they die on average 25 years younger than the general population,” reveals Madeline Rivera, R.N., Chief of Clinical integration at Brooklyn Health Home.

Madeline Rivera, R.N.

Karen Nelson, M.D., Vice-Chair, Department of Population Health and Executive Director of the Brooklyn Health Home, says that is part of the reason why the health center began down this path in the first place.  “In some ways there is so much trouble with it, you can make a lot more progress,” Dr. Nelson says. “If you go into the ER, the [lack of] coordination is so gigantic across the board. There were thousands of examples of SMI patients bouncing around. It’s so ho-hum in the medical care, everything is so uncoordinated. It’s worse because in some ways [those patients] are needier.”

Maimoides Medical Center Source: Maimonides Medical Center


The genesis of the virtual co-location project was a successful single pilot at the South Beach Psychiatric Center in conjunction with Maimonides, which began in 2006 (see sidebar). From there, thanks to significant grant money and a partnership with various health information exchange (HIE) organizations, the mental health home concept has blossomed into a borough-wide phenomenon.

SIDEBAR: Promising Beginnings of a Pilot

In 2006, Maimonides initiated a pilot with the South Beach Psychiatric Center to serve Medicaid enrollees with SMI that had little access to primary care. That virtual co-location pilot ultimately led to the development of the Brooklyn Health Home. The results of that pilot speaks for itself:
44% Decline in Medical ER Visits
17% Decline in Psychiatric ER Visits
7% Decline in Inpatient Medical Admissions
26% Decline in Inpatient Psychiatric Discharges

Based on the success of the South Beach pilot, the Maimonides team earned two Health Care Efficiency and Affordability Law (HEAL) grants, in 2010 and 2011, to further develop the mental health home model. Around this time, according to Nelson, the state of New York coincidentally began recruiting health homes to support coordination. By the end of the 2011, Brooklyn Health Home was designated for a Medicaid Health Home by the New York State Department of Health (DOH). In 2012, the Centers for Medicare and Medicaid Innovation (CMMI) awarded Maimonides a three-year Health Care Innovation Award (grant) to focus on 7,500 patients with SMI.

Over time, as this grant money came in, more area partners joined with Maimonides to eventually form the consortium. These grant funds have allowed the Brooklyn Health Home consortium to build up the health information technology infrastructure that makes this kind of care coordination possible. The platform, from Philadelphia-based, GSI Health and built on a multi-tier service oriented architecture (SOA) and web services framework, is interoperable with the Statewide Health Information Network for New York (SHIN-NY).

Using the regional health information organization (RHIO), Brooklyn Health Information Exchange (BHIX), which recently merged with New York-based Healthix, Inc., the care coordination platform provides core clinical information through Health Level Seven, Inc. (HL7) and Integrating the Healthcare Enterprise (IHE) standards-based continuity of care documents.

“We want to get the holistic idea of a patient’s situation,” explains Michael Carbery, the Brooklyn Health Home CIO and Assistant Vice President of HIE. “And because of what we’re trying to accomplish, we’re reliant on standards.”

Michael Carbery

This interoperability allows for the platform to integrate new clinical information in real-time, and trigger an event notification to the patient’s care provider team. Additionally, thanks to front integration through single-sign on (SSO), the platform allows users to easily message other providers securely, engage patients, provide clinical decision support, and undergo analytics through a suite of add-on applications, presented in a dashboard format.


Naturally, the health home needs more than just IT to be successful. SMI patients within the health home (as well as the other patients in the Medicaid-based Brooklyn Health Home) are assigned care managers. Those care managers, according to Rivera, are the “boots on the ground.”

These care managers serve as the hub for the patients, monitoring and sharing the electronic alerts and community wide clinical information. One of the challenges Maimonides and other consortium stakeholders have faced with this initiative is getting the care managers to work with the hospitals and other clinical providers to understand the value of this care coordination. According to Jenny Tsang-Quinn, Assistant Vice President, Primary Care Services and Chief of Clinical Network Development, this happens all the time.

“We hear it every day. This provider didn’t know what a health home was or didn’t know what a care manager does,” Tsang-Quinn says. The need for better communication between organizations in and out of the health home is one of the prominent challenges Maimonides and the others face. Both Rivera and Tsang-Quinn note that once providers use the platform, they understand the value-add that it offers.

Jenny Tsang-Quinn

Like other healthcare organizations attempting to coordinate care, this consortium is still staring up a metaphorical mountain of misaligned incentives, information silos, and in this case, a lack of standards for behavioral healthcare clinical measures. Despite this steep obstacle, the leaders of this project ultimately see what they are trying to accomplish, and have already accomplished, as a replicable model for care delivery across the industry.

“I think coordinating patient care is not the sum of all the pieces of paper, it’s the person to person. It’s amazing to do it. Most are relying on building a bigger and bigger system, and I don’t think that’s the answer to coordination. Pulled off of all that data is a place where you’re just coordinating care for people when they are complicated,” Nelson says. “If you could use that system, it would be amazing.”

Grant or no grant money, Carbery says the organization plans to continue down this path for the foreseeable future. “We call it healing the mind body split,” he says.

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