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Montefiore in the News

August 15, 2012

Report Includes Data Illustrating how Care Coordination Programs can Improve Patient Outcomes,
 Reduce Hospital Admissions, Readmissions and Medical Expenses

New York City, NY (August 15, 2012) Montefiore Medical Center is profiled in a report published today on The Agency for Healthcare Research and Quality (AHRQ) Innovations website. The report, entitled “Medical Center Establishes Infrastructure to Manage Care under Capitated Contracts, Leading to Better Chronic Care Management and Lower Utilization and Costs,” explores Montefiore’s extensive care management experience, consistent with the principles of an Accountable Care Organization, and highlights its success in improving outcomes for patients with chronic disease.

Montefiore’s expertise in proactively managing care, while simultaneously lowering costs, led to its selection in December 2011 by the Centers for Medicare & Medicaid Innovation (CMMI) to participate in the Pioneer Accountable Care Organization Program.  The Montefiore Pioneer Accountable Care Organization (ACO) is one of only 32 Pioneer ACOs in the nation and the only Pioneer ACO in New York State. While the Pioneer Program is a new federal initiative intended to provide Medicare beneficiaries with higher quality care and reduce expenditures through enhanced care coordination, Montefiore has a long history of providing comprehensive care management services, under contractual relationships with health plans. Montefiore has offered advance models of care coordination and innovative payment methodologies since 1996 and the AHRQ report highlights Montefiore’s success in achieving improved outcomes, including fewer hospital admissions and readmissions, and lower medical expenses for health plan members with diabetes, asthma and congestive heart failure.

“We care for a very fragile and vulnerable population at Montefiore and this report demonstrates that with the right infrastructure, dedicated teams of physicians, nurses, care managers and behavioral health specialists and a deep commitment to providing care across multiple settings, it is possible to improve the health of even the most vulnerable patients,” said Stephen Rosenthal, President and COO Montefiore’s Care Management Company.

“We established the Care Management Company 16 years ago because we recognized the importance of focusing on the prevention of health problems rather than just treating them,” said Mr. Rosenthal. “By implementing interventions and providing high quality, coordinated care, we created a model which would allow us to track and maintain the health of a population, currently numbering approximately  200,000 people, while lowering costs. And now, this approach has become a model for healthcare providers nationwide.”

The AHRQ report describes various programs implemented by Montefiore to comprehensively manage care, which begins with the development of individualized care plans for patients with chronic or complex conditions. Among the initiatives is the House Calls Program which provides primary care for the homebound elderly, enabling them to maintain an independent lifestyle. Services include physical exams, preventive screenings, in-home medical tests, medication reconciliation, telemonitoring, and psychosocial support. The report also addresses the benefits of Montefiore’s value-based capitation programs, compared to the traditional fee-for-service payment models which often result in ineffective, fragmented care.

Data from 2007 – 2010 cited in the report illustrates Montefiore’s success in managing chronic diseases, including lowered HbA1c levels in diabetic patients, reduced ED visits and inpatient admissions amongst asthmatic patients and declines in admissions, readmissions, and medical expenses among other key populations. Montefiore attributes its success to its many comprehensive care management programs and its integrated network of four hospitals, 21 community-based primary care centers, school-based health centers, and mobile clinics, seamlessly connected by Electronic Medical Records, an invaluable tool in tracking the health of its patients.

The report outlines key steps carried out by Montefiore to address and resolve issues that many healthcare providers nationwide still face today, such as establishing protocols to guide care for patients with various chronic diseases. It highlights the importance of engaging and garnering support from leadership as well as employed and community-based physicians. The report demonstrates how Montefiore has created a systematic process for care management, evaluation and continuous quality improvement. It also emphasizes the necessity to develop a dedicated team approach within a seamless health care delivery system, to provide superior access, quality, safety and patient satisfaction.