June 20, 2018  Vol. 4, No. 11

Changing Patient Lives with the MAX Series

SOMOS has participated in the Medicaid Accelerated eXchange or (“MAX”) Series program for two highly successful years. During the 2017 MAX Series High-Utilizer Inpatient program initiative with Jamaica Hospital, SOMOS was able to develop and implement innovative, collaborative, quality improvement strategies to ensure effective and efficient delivery of care to the high-utilizer inpatient population.  As of a result of this integrated approach to reduce avoidable hospitalizations, the team developed a more comprehensive, integrated, and patient-centered quality delivery system considering the medical, behavioral health and social determinates of health factors which impact patient care.     

During this joint initiative, team members encountered a 43-year-old male that had been hospitalized six times in last twelve months due to alcoholic liver disease, seizures, anemia, hepatorenal syndrome and three times weekly dialysis treatments. Upon completing a comprehensive patient assessment, it was identified that the patient was non-compliant with dialysis due to a late appointment slot at a care center far from the patient’s home, financial hardship, undocumented status, and a need for primary care.

Apart from the patient’s medical needs, the ED nurse was able to effectively address his social determinates of health barriers to care:

  • Warm-handoff to a social worker at his current dialysis center
  • Facilitated a transfer to a dialysis center in the patient’s community with an earlier appointment time
  • Referral to the River Fund through which the patient and his wife can receive food, toiletries, clothing, and legal/immigration resources
  • Coordinated approval of financial aid through the hospital, and initiated a relationship with a SOMOS Primary Care Physician

Thanks to this intervention, the patient has been able to adhere to his dialysis treatments, receive quality primary care, and effectively use public support to address his social determinates of health. As a result, he has not returned to the ED in the last five months post-discharge.

Yesterday, the New York State Department of Health announced that through the MAX Series, avoidable hospital use for the state’s most vulnerable patients has been significantly reduced. Since its launch in 2015, the MAX Series has been an integral part of the Department’s strategy toward successfully achieving DSRIP goals. To date, the MAX effort has tracked 15,000 patients across the state. Click here for more information on the MAX Series.

SOMOS General Assembly and Employee Recognition

SOMOS Community Care staff members joined for a General Assembly on Wednesday, June 13 where the staff was given a glimpse into SOMOS' future. Some highlights included:

  • A panel discussion on VBP and life after DSRIP including SOMOS Chief Operating Officer David Steinman, Chief Business Development Officer Ricardo A. Rivera-Cardona, and Vice President of Workforce, Community, and Government Relations  Moisés Pérez-Martínez as panelists.
  • SOMOS' Communications team presented on the new SOMOS website and citywide advertising campaign.
  • SOMOS Consulting Medical Director Dr. Richard Bernstein delivered an inspirational talk about how our everyday work can be transformed into a legacy for the future. He used as examples the mason building the Empire State Building, the Chinese landscape painter creating magnificent art, and our work with medically underserved populations.  All three began with a vision of something much bigger than ourselves.
  • Chief Medical Officer Diego A. Ponieman, M.D., M.P.H. delivered an educational presentation on plant-based diets and how applying the principles used in "Blue Zones" can change the trajectory of our health, and in turn, our lives.
  • The introduction of Andrea DiMedio's promotion to SOMOS Risk Manager. Mrs. DiMedio will work with Operations, Finance, Legal, Human Resources, IT, and Compliance to develop resolutions and streamline its response to matters that require further investigation and address potential risks to the organization regarding its internal and external affairs. 

During the event, SOMOS CEO Mario J. Paredes and Vice President of Human Resources Liz Webb joined in honoring two SOMOS employees for their dedication and exemplary service with Employee Recognition Awards. The recipients of the Employee Recognition Awards were Practice Transformation Team Lead Peter Xie (pictured right) and Human Resources Representative Yolanda Rodriguez.

SOMOS Hosts All-Partners Meeting

SOMOS hosted a successful All-Partners Meeting on Thursday, May 31 where over 60 SOMOS partners joined in learning about providing better quality, patient-centered care. The meeting discussed partner engagement for effective outcomes, performance and Funds Flow, the importance of adhering to guidelines for performance incentive payments, defining workflows and reporting, and collaborating effectively amongst community-based providers and organizations. A Q&A session gave Partners the opportunity to raise important questions, answered by Lidia Virgil, Vice President of Health Care Innovation, and Moises Perez-Martinez, Vice President of Workforce, Community, and Government Relations. 

DEADLINE NEXT WEEK: Sprint to Open Care Gaps by June 30, 2018

SOMOS Community Care is conducting a sprint to close open gaps in care. Your attention and support are needed to help close these open gaps in care by June 30, 2018 and submit claims prior to September 30, 2018. As we enter the last two months of the measurement year (July 1, 2017 to June 30, 2018), the SOMOS Practice Transformation team will be working closely with your practice to provide the support that you need to deliver the highest quality health care, and perform as well as possible so that we can all meet our goals.

Reaching these measures means financial benefit for the entire SOMOS Community Care network as well as your practice! As a reminder, here are the measures we are prioritizing, and how we can support you in achieving them:


We are here for you!

Our goal is to assist your practice in the delivery of continuous high-performing primary care while improving your patient’s health outcomes and increasing office efficiency and revenue. 

Have a question? Please contact Brandon Phan by emailing bphan@somoscommunitycare.org.

Making Healthier Choices with DASH
Dietary Approaches to Stop Hypertension Nutrition Plan

SOMOS' DASH Nutrition campaign has taken shape in the form of citywide events, seminars, multilingual videos, and a DASH-dedicated blog. Here are the current developments. 

Educating NYC on DASH

SOMOS Vice President of Communications Denisse Oller visited the Northern Manhattan Improvement Corporation in Washington Heights, NYC where she addressed a group of 30 Latinas who are part of a special program for survivors of domestic violence. 

DASH, which stands for "Dietary Approaches to Stop Hypertension," is an award-winning diet developed by the National Heart, Lung, and Blood Institute proven to lower blood pressure, reduce cholesterol, and improve insulin sensitivity.  It emphasizes eating whole foods — such as fruits, vegetables, whole grains, fish, poultry, beans, nuts, and vegetable oils — and limits foods high in saturated fat. It also limits sugar-sweetened beverages and foods creating a completely balanced diet that can be customized for any culture and cuisine.

Interested in hosting a DASH Nutrition Plan workshop at your practice or facility? Contact Miriam Mejia at mmejia@somoscommunitycare.org for more information.

SOMOS and Stanford Model Self-Management Program 

Engaging patients in self-management of their chronic disease is an important step toward improving health outcomes and reducing the cost of healthcare. Because of this, SOMOS staff has been trained and certified in the Stanford Model and facilitate Stanford Model Self-Management workshops for patients with diabetes, as part of DSRIP Project 3.c.i.

SOMOS hosted a Diabetes Self-Management Program Cross-Training where a mix of SOMOS patient engagement staff members, Evolent employees, NYS Department of Health members, staff from SOMOS physician Dr. Goris' office, and other partnering agencies and institutions became certified Master Trainers. The certification allows them to train others to be Diabetes Self-Management trainers, able to facilitate self-management workshops on their own. 

Chronic Disease Self-Management workshops (CDSMP) are offered to patients with Asthma, Cardiovascular, or other chronic illnesses like COPD. Diabetes self-management workshops are offered to patients who have A1c levels at a 6.5 or higher, and Pre-Diabetes classes – following the National Pre-Diabetes Prevention Program (NDPP) – are offered to patients who have A1c levels between a 5.7% and 6.4%.

Interested in hosting a Pre-diabetes (NDPP), Diabetes Self-Management (DSMP), or Chronic Disease Self-Management workshop at your practice? Contact Miriam Mejia for more information.

Diabetes Self-Management Program graduates from Dr. Fausto Gonzalez's Medical Practice in Washington Heights pictured with SOMOS program leaders Miriam Mejia and Solangiel Suarez.

SOMOS Community Care Blog

The Basics of Men's Health
by Diego Ponieman, MD MPH

In honor of June being National Men’s Health Month, let’s address some of the biggest health concerns facing men today, the ways to prevent them, and how men can live a healthy, happy lifestyle.​ Some of the top health risks for men in the United States include heart disease, depression, chronic lower respiratory disease, stroke, prostate cancer, and unintentional injuries. Here at SOMOS, we have collected some of these solutions and methods, but it’s important to always consult with your primary care physician to figure out the best plan of action for you.


Read more...

An Active NYC Summer
by Denisse Oller

The sun is out, temperatures are up, and school is quickly coming to an end. The start of summer vacation is an exciting time, but it can also require an adjustment for many families. Kids are in school for most of the year, staying engaged mentally and physically in class and during after-school activities. With the start of the summer right around the corner, families have the perfect opportunity to introduce new routines that encourage healthy physical activity while enjoying time together.​

Read more...



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