Site Profile: Mount Sinai Doctors - West 147th Street


Location: New York, NY
Practice Type: One of 42 primary care clinics owned by the Mount Sinai Health System
Primary Care Providers: A mix of eight full-time and part-time providers
Approximate Annual Patient Visits: 14,280
Reimbursement Model: Fee-for-service, with some value-based-reimbursement

Mount Sinai Doctors - West 147th Street in Harlem, N.Y., previously part of the St. Luke’s Roosevelt Health System, is one of three sister clinics that provide community health services to the West Harlem and Morningside Heights communities in Manhattan, and is closely affiliated to Mount Sinai St. Luke’s Hospital in the same area.

In addition to seven full-time physicians, the clinic consists of one practice manager, five front desk specialists, one medical records specialist, five medical assistants, one part-time clinical pharmacist, two care coordinators who work part time and remotely to coordinate care for patients with the most complex and highest-needs and a referral specialist who also works remotely. The ratio of physicians to medical assistants at the practice is 5.6 full-time equivalent MDs to five MAs.

Prioritized Modules for Practice Transformation


What is a module?

A module is a project a practice undertakes based on the priorities it has identified. Each module contains a set of highly-specified end-states against which practice teams self-assess and develop work plans to fulfill based on their own contexts.

A Practice-Wide Approach to Access for Empaneled Patients

The practice identified its access policy as an area of potential improvement. In its assessment, the fact that it was accepting walk-in patients was leading them to double-book patients, working them into physicians’ schedules at the end of the day and over lunch. This policy was causing longer patient wait times, making it difficult to manage patient load and contributing to a stressful environment for the entire practice team.

Delegating Administrative and Clinical Tasks

By reorganizing its care teams and redistributing its workload, the practice reduced the amount of time its providers spent on administrative and lower-level clinical tasks—allowing them more time to care for their most complex patients.

Collecting and Managing Data

The practice put a system in place to know if a patient attended his or her specialist, imaging or lab appointment upon referral, and that the appropriate documentation was received by the practice.

Using Data to Proactively Identify and Close Care Gaps

With the goal of reducing care gaps among those with the highest need and most complex cases, the practice selected four measures (diabetics with hypertension, hypertension, pneumococcal vaccination, and tobacco screening and cessation) to track patients who are due for follow-up or preventative care.