Mount Sinai Hospital Launches Initiative to Improve Transitions of Care for Venous Thromboembolism Patients

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Focus on development and adoption of new approaches

The Department of Medicine at the Icahn School of Medicine at Mount Sinai has been awarded a half-million dollar grant funded by Pfizer Independent Grants for Learning & Change (IGLC) and Bristol-Myers Squibb Independent Medical Education (IME). The grant focuses on accelerating the development and adoption of evidence-based approaches to improve the safety and effectiveness of patients with the diagnosis of venous thromboembolism (VTE) as they move from one care setting to another. The Joint Commission led the evaluation process, provided oversight of the committee that made funding decisions and is solely responsible for administering and overseeing project activities for Mount Sinai and four other institutions that are receiving similar grants. The $500,000, 24 month award will fund a novel, multi-faceted initiative which includes the development of a care bundle and a smartphone app focused on transitions of care for patients with venous thromboembolism, a potentially life-threatening condition which frequently requires hospitalization and post-discharge management with medication.

VTE includes two conditions. Deep-vein thrombosis (DVT) is the formation of blood clots in the deep veins of the legs; pulmonary embolism (PE) occurs when a blood clot detaches from the wall of the leg vein and moves to the lungs, causing difficulty breathing. The treatment of both conditions involves the use of intravenous or oral anticoagulant medication and can take several months. While treatment often begins in a hospital setting, most patients transition to home or another outpatient setting immediately after discharge.

“Successfully treating venous thromboembolism requires a great deal of coordinated care,” said Eric Goodman, MD, Instructor of Medicine in the Division of Hospital Medicine at the Icahn School of Medicine at Mount Sinai and the study’s principal investigator. “It can be hard for many patients to manage their treatment on their own. We feel that this program will help provide high quality and well-coordinated care as VTE patients leave the hospital and continue their treatment as an outpatient.”

The grant, which is the largest ever received by the Department of Medicine at the Icahn School of Medicine at Mount Sinai for a quality improvement initiative, will be used to develop a new program to help VTE patients leaving the hospital to successfully continue complex treatment regimens in an outpatient setting. The study team, which also includes co-Investigators Beth Raucher, MD, Vice Chair of Medicine for Quality and Clinical Affairs; Andrew Dunn, MD, Chief of the Division of Hospital Medicine; Julie Pearson, MPH, Quality Data Analyst; Ashish Atreja, MD, Director of the Sinai AppLab and Chief Technology Innovation and Engagement Officer in the Department of Medicine; and Milan Patel, MS, Senior Systems Software Specialist for the Mount Sinai AppLab, will develop and oversee the VTE transitions of care bundle. The goal of the study is to reduce recurrence of VTE and to minimize serious medication-related adverse events, as well as to reduce hospital readmission by staying in close contact with the patient using the smartphone app. Mount Sinai has successfully used a similar app to help patients with Inflammatory Bowel Disease manage their health.

The cloud-based smartphone app will be used to collect patient data on medication adherence and symptom progression, and will facilitate communication with the care team. Data from the app and other components of the VTE Bundle will be aggregated into an electronic dashboard, which will be fully integrated with the electronic health record system used at Mount Sinai to facilitate coordination of care.

In addition, a licensed clinical social worker will meet the patients at their bedside to help them and family members become acquainted with the app and other aspects of the transition to outpatient care and necessary follow-up. Through the app, the navigator will remain in contact with patients to help them adhere to their medication plans and attend their follow up appointments, and will help facilitate communication with their primary care provider for medical issues related to VTE.

About the Mount Sinai Health System
The Mount Sinai Health System is an integrated health system committed to providing distinguished care, conducting transformative research, and advancing biomedical education. Structured around seven hospital campuses and a single medical school, the Health System has an extensive ambulatory network and a range of inpatient and outpatient services—from community-based facilities to tertiary and quaternary care.

The System includes approximately 6,100 primary and specialty care physicians; 12 joint-venture ambulatory surgery centers; more than 140 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. Physicians are affiliated with the renowned Icahn School of Medicine at Mount Sinai, which is ranked among the highest in the nation in National Institutes of Health funding per investigator. The Mount Sinai Hospital is ranked as one of the nation’s top 10 hospitals in Geriatrics, Cardiology/Heart Surgery, and Gastroenterology, and is in the top 25 in five other specialties in the 2014-2015 “Best Hospitals” issue of U.S. News & World Report. Mount Sinai’s Kravis Children’s Hospital also is ranked in seven out of ten pediatric specialties by U.S. News & World Report. The New York Eye and Ear Infirmary of Mount Sinai is ranked 11th nationally for Ophthalmology, while Mount Sinai Beth Israel is ranked regionally.    

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David Slotnick
Mount Sinai Health System
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