PROJECT SUMMARY
The Mount Sinai Center for Post-COVID care has provided specialized evaluation and treatment services for
adult Long COVID patients since 2020. The Center operates as a specialty referral service staffed by
clinicians, social workers and care navigators. Yet unlike other specialties, it is fully integrated in primary care
(PC), which facilitates referrals, access to PC-based services like depression treatment, and seamless
transitions back to PC after the need for specialty Long COVID care is complete. The program has served over
6000 patients to date. However, the Center's reach has been limited. Its two locations, in Manhattan's Lower
East Side and Upper West Side are out of reach for most residents of New York City communities hard hit by
COVID-19, including the minoritized and low income residents of Harlem and the South Bronx. Resource
constraints, including staffing and protected time, have limited the ability of Center leaders to extend access to
care for patients, reduce waiting times for evaluations, introduce practice innovations and keep up with
changes in the field. For these reasons, we propose a project that would add a third site to the Center for Post-
COVID care integrated in Mount Sinai's Internal Medicine Associates (IMA) PC practice in East Harlem and
build resources and processes that continually improve Long COVID care and extend its reach in a sustainable
way. The new practice will be staffed by PC providers with expertise in Long COVID care, a neuropsychologist,
social worker and health navigators. In project Phase 1, the project team will create and regularly update
clinical decision pathways to guide clinicians through the evaluation and care of Long COVID patients and
embed them in the electronic medical record (EMR). We will provide patients with comprehensive, highly
patient-centered and coordinated care that involves point-of-care evaluations like cognitive assessment and
pulmonary function testing, care navigation, and facilitated access to PC-based clinical services like mental
health care and to specialists throughout the Mount Sinai Health System. We will partner with two community-
based health and social service providers to develop and implement patient engagement and referral
strategies to increase awareness of Long COVID and access to care for it among Harlem and South Bronx
residents, and link patients to social services for wrap-around care. We will also develop a comprehensive
education program for the benefit of the specialized Long COVID team and the local PC providers, and collect
and analyze data for program evaluation and continuous quality improvement. In project Phase 2, we will
develop the Long COVID knowledge and clinical skills of PC physicians in IMA and other PC practices
(`satellite practices), train them to use the EMR-embedded CDS and provide them access to Long COVID
specialist e-consults and referrals so that they can manage Long COVID patients of low complexity.
