Montefiore Medical Center has been selected as one of 15 hospitals in the country to participate in the American College of Cardiology Patient Navigator Program. This first-of-its-kind program in Cardiology is designed to support hospitals in providing personalized services to heart disease patients and help them avoid a quick return to the hospital.

"We are honored to be selected for this important pilot program. Improving transitions of care for patients with heart disease and reducing readmissions are a constant focus at Montefiore and are a growing area of concern for healthcare as a whole," said Ileana Piña, M.D., M.P.H., associate chief, Academic Affairs, Division of Cardiology, Montefiore, professor of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine of Yeshiva University. "The Patient Navigator Program will allow us to support a team of experts focused on these patients and will allow for the appropriate care and education to be offered, thus improving outcomes."

Nearly one in five patients hospitalized with heart attack and one in four patients hospitalized with heart failure are readmitted within 30 days of discharge, often for conditions seemingly unrelated to the original diagnosis. Readmissions can be related to issues like stresses within the hospital, fragility on discharge, lack of understanding of discharge instructions and inability to carry out discharge instructions.

The Patient Navigator Program Team at Montefiore consists of a cardiologist, a nurse with heart failure care experience, a rehabilitation professional with exercise therapy experience and a PharmD. The team serves as the patient's advocate for the totality of their transition of care and aims to discharge patients on a timely basis, identify those who are high risk for readmission and provide resources to help prevent avoidable readmissions.

"We believe strongly in the team approach to medicine, especially for patients suffering from serious heart conditions" said Dr. Piña. "In addition to our core team, we also include nutritionists, mental health experts and social workers in this process. We are prepared to offer any support needed to make a patient's transition home a success."

The ACC created the Patient Navigator Program to support a team of caregivers at selected hospitals to help patients overcome challenges during their hospital stay and in the weeks following discharge when they are most vulnerable. Hospitals chosen were given funding to establish a program in support of a culture of patient-centered care that can be implemented in other hospitals in the future. AstraZeneca is the founding sponsor of the ACC Patient Navigator Program.

"The ACC Patient Navigator Program will serve as a test for innovative, patient-centered solutions to address issues that impact patient health and patient readmissions," said ACC President John G. Harold, M.D., M.A.C.C. "Montefiore is a pioneer in a new approach to heart disease treatment and care that puts emphasis on a team approach to meeting patients' ongoing needs and helping patients make a seamless transition from the hospital to the home."

By the end of 2015, the ACC will enroll at least 35 hospitals in the Patient Navigator Program.

  Participants in the award presentation included (L to R): Don Stark, director of Clinical and Business Affairs, Division of Cardiology, Montefiore; Ileana Piña, M.D., M.P.H., associate chief, Academic Affairs, Division of Cardiology, Montefiore, professor of Medicine and Epidemiology & Population Health, Einstein; Auris Browne, director, Clinical Trials and Regulatory Affairs, Division of Cardiology, Montefiore; Mario Garcia, M.D., chief, Division of Cardiology, Montefiore, and co-director of The Montefiore Einstein Center for Heart and Vascular Care; Shilpa Patel, Senior Specialist, Science, Education and Quality for ACC; Nicole Wilson, Director of Corporate Relations, ACC; Henry Solomon, MD, FACC, Senior Medical Advisor, ACC; James J. (Terry) Ferguson, MD is the Vice President of Global Medical Affairs/ Cardiovascular/Astra Zeneca