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2014 Social Work Recognition Night - Social Work Leadership in the Affordable Care Act: A Care Coordination Model

Date: September 15, 2014
Time: 5:00 PM - 7:00 PM


Susan R. Bernstein, DSW, LCSW; Maria Basso Lipani, LCSW,;Christine Hamilton, PhD, LCSW, MPH; Kristina Monti, LCSW; Arielle Rosner, LCSW; Nancy Xenakis, LCSW, MS

Sponsored by: The NYAM Section on Social Work, The NYAM Section on Health Care Delivery, Alpine Home Health Care and the Silberman School of Social Work at Hunter College

Location: The New York Academy of Medicine, 1216 Fifth Avenue at 103rd Street, New York, NY 10029

Please join us in recognizing the achievements of Dr. Susan Bernstein, Director of Social Work Services, Mount Sinai Hospital and her team of social work leaders.

The Affordable Care Act, passed by Congress in 2010, aims to move the healthcare system away from its current episodic, fee-for-service payment approach and towards a coordinated model that is focused on delivering high-quality, low-cost care across the continuum of care.

In 2012, Mount Sinai began its work in population health management by developing a social work-led care coordination model focused on the psychosocial drivers of unnecessary medical utilization, primarily ED visits and readmissions. Currently Mount Sinai has four distinct care coordination programs funded by CMS and NYSDOH, all focused on the triple aim of improving the health of individuals, improving the health of the overall population resulting in a reduction of overall health care expenditures.

Dr. Bernstein and her leadership team will share the principles upon which the models are based, outcomes achieved, the skills social workers need, and the challenges faced to practice in a new health care environment.


Special thanks to Alpine Home Health Care and the Silberman School of Social Work at Hunter College for sponsoring this event.

About the Speaker(s)


Susan R. Bernstein, DSW, LCSW, Director, Department of Social Work Services

Susan Bernstein, DSW, LCSW has been at Mount Sinai in the Department of Social Work Services since 1990 and has served as Director since 2007. She received her Doctorate of Social Work from the City University of New York and her Master’s degree in Social Work from the University of Southern California.

Panel Members

Maria Basso Lipani, LCSW, Director, Preventable Admissions Care Team (PACT), CMS, CCTP Funding

Maria Basso Lipani, LCSW is the Director of the PACT (Preventable Admissions Care Team) Program at Mount Sinai Hospital and the developer of the PACT Program Model. Prior to PACT, Maria managed the CAPP Caregiver Resource Center at Mount Sinai and has also provided supportive services to older adults and their family members at Kaiser Permanente in San Francisco and to widows of those lost on 9/11 in Brooklyn. Maria received her Master’s degree in Social Work from Columbia University.

Christine Hamilton, PhD, LCSW, MPH, Assistant Director, Medicine/Surgery (GEDI-WISE Program) CMS, CMMI Funding

Christine Hamilton, PhD, LCSW, MPH is currently the Assistant Director of Social Work in Adult Medical Services. She has held clinical, supervisory, and administrative positions in both acute care hospitals and long term care facilities and was the Director of Social Work at Amsterdam Nursing Home for over ten years. Dr. Hamilton received her PhD from New York University and her Master’s degrees in Social Work and Public Health from Columbia University.

Kristina Monti, LCSW, Program Coordinator, Medicaid Health Home

Kristina Monti, LCSW is a Program Coordinator for the Mount Sinai Health Home and was formerly at Mount Sinai Beth Israel where she worked as the Clinical Supervisor of the inpatient detoxification unit.  Ms. Monti’s career has included work as a Social Worker in adult behavioral health at Albert Einstein College of Medicine and Mount Sinai Beth Israel’s methadone maintenance treatment program. Ms. Monti received her Master’s degree in Social Work from Simmons College and is currently a PhD Candidate and Adjunct Professor at the Adelphi University. 

Arielle Rosner, LCSW, Program Coordinator, Medicaid Health Home

Arielle Rosner, LCSW is a Program Coordinator for the Mount Sinai Health Home. She has worked at Mount Sinai Medical Center since June 2009 where she began in the Renal Transplant Department and followed patients through all phases of the transplant process. Ms Rosner also teaches small group sessions within the Mount Sinai School of Medicine for the first year course, The Art and Science of Medicine. She received her Master’s degree in Social Work from Columbia University.

Nancy Xenakis, LCSW, MS, Associate Director, Department of Social Work Services (Former Director, Care Coordination), CMS, ACO & NYS Medicaid Health Home

Nancy Xenakis, LCSW, MS is the Associate Director, Social Work Services. She returned to Mount Sinai in 2012 as the Director of Care Coordination at Mount Sinai Care, the Accountable Care Organization. She has held clinical and leadership positions in three academic medical centers, a community-based organization and a graduate social work program.  She received her Master’s degrees in Social Work and Health Policy and Management from New York University.


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Cost: Free, but advanced registration is required
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