• Integrated Care Delivery for Vulnerable Populations

    Dec 13, 2010

    By Deborah Chase

    Montefiore Medical Center is meeting the exceptional challenge of serving a disproportionately poor and sick population.

    Low-income, vulnerable populations are historically complex to care for, and the health systems that dedicate themselves to this service often remain in precarious financial and organizational positions.

    Montefiore Medical Center is an exception.

    A not-for-profit academic medical center in the Bronx borough of New York City, Montefiore has created an integrated system of care for its primarily low-income patients. Although close to 80 percent of its payer mix is Medicaid and Medicare, Montefiore has been able to achieve financial and organizational sustainability.

    In 2009, the system had an operating margin of 1.3 percent and a total margin of 2.5 percent. Montefiore's average inpatient length of stay dropped from 8.7 days in 1993 to 5.4 days in 2009, compared with 7.2 days for New York State hospitals and 6.7 days for New York City hospitals.

    At the same time, patients are benefiting. Overall mortality rates at Montefiore fell to 1.76 in 2008, from 3.5 percent in 1997. In addition, Montefiore scores higher than average for New York State on most HCAHPS measures of patients' experiences with care.

    Factors for Success

    In recent years, Montefiore has sharpened its focus on the needs of the community and patients and redoubled its emphasis on performance improvement. The patient-centered system includes four hospitals, 21 community clinics, and 17 school-based clinics. Factors for success include the following.

    Primary care and chronic disease management. Montefiore leaders have focused on building primary care and clinic sites to meet the complex needs of vulnerable populations. At the same time, they have reached out to the community to better understand patients' needs and to create solutions involving strong community partnerships, public health, and social services that reach beyond traditional medical care.

    Here are three examples:

    • Establishing patient-centered primary care: Montefiore is piloting patient-centered medical homes at two of its primary care centers, and hopes to replicate the pilots at other sites. A mix of high-tech and low-tech approaches-from extended and weekend hours to patient-to-physician e-mail-are being used to increase access and continuity.
    • Improving diabetes care: The diabetes initiative encompasses neighborhood- and home-based efforts focused on nutrition and educations. Rates of glycemic control across ambulatory sites now exceed published benchmarks.
    • Improving asthma care in the hospital and the community: Montefiore partners with the New York City Department of Education to provide primary care in the Bronx public schools. Elementary school children with asthma who attended schools with a Montefiore clinic had a 50 percent reduction in hospitalizations and ED visits compared with asthmatic children in schools without a clinic.

    Access to high-quality specialty and hospital care. Montefiore is home to clinical programs that rank among the top in the nation. Here are two examples:

    • Emergency department innovations: Montefiore improved its door-to-balloon rate to 88 percent to 100 percent in 2009, compared to 11 percent in 2006. At a quality improvement team's recommendation, Montefiore invested in a dedicated phone network for use in managing heart attack patients, with one phone in the ED and one carried by all cardiology catheterization team members. In addition, all team members carry dedicated pagers.
    • Critical care expertise: The director of critical care at Montefiore created the "ICU without walls" initiative that provides rapid response by a critical care medicine expert systemwide. The round-the-clock presence of board-certified intensivists caring for patients in and out of the ICU has been a significant contributor to a 40 percent decrease in inpatient mortality in the past decade, according to Montefiore leadership.

    Targeted care management. In 1996, Montefiore established CMO, The Care Management Company as a wholly owned subsidiary. The CMO manages risk for the medical center and for Montefiore's integrated provider organization (IPA). The CMO also provides care management, customer service, provider relations, and claims processing services under delegated arrangements with health plans.

    The 150,000 patients enrolled in the CMO via capitated contracts represent only one third of Montefiore's total patient population. However, the CMO has served as an incubator for developing systemwide strategies to manage chronic disease, improve quality of life, reduce hospitalizations, and create efficiencies.

    The CMO uses its network management expertise to focus on coordinating and improving care for patients across the continuum of acute and ambulatory care. For example, CMO network managers help coordinate care transitions, provide patient education, manage chronic disease, increase access to specialty care for ambulatory care patients, and provide on-site case managers at clinic sites.

    Results to date include the following:

    • Use of telemonitoring tools for diabetes and congestive heart failure patients resulted in 9 percent to 32 percent decreases in annual costs compared with the year before enrollment in disease management.
    • Nurse phone calls to recently discharged elderly patients resulted in a reduction in the 30-day readmission rate in that group from 19.9 percent to 13.2 percent.
    • Among patients enrolled in the CMO house calls program, hospital admissions, ED visits, and total costs were reduced by one third after one year-and these gains were sustained after two year.

    Robust health IT. Montefiore began developing its health IT system in 1995. Since then, it has invested close to $200 million. The inpatient EHR is fully operational at three Montefiore hospitals; implementation at a newly acquired fourth hospital is in progress. The ambulatory EHR is being implemented at multiple primary and specialty sites. The plan is to have 70 practice locations fully operational by fourth quarter of 2011.

    Highlights of Montefiore's IT achievements include:

    • In 1999, the inpatient service fully implemented computerized physician order entry (COPD). By 2000, the medical center showed that CPOE and electronic pharmacy dispensing systems had reduced potential medication errors by 80 percent.
    • Each patient in the Montefiore network has a unique patient identifier that is tied to his or her lifetime electronic patient record-and is used throughout the Montefiore network.
    • Patients can e-mail their physicians via a secure, Internet-based messaging service; currently 16 percent of ambulatory care patients are using the portal and 750 physicians participate.
    • Montefiore's data warehouse enables searches of aggregated data and permits assessment of performance by physician, department, or site of care. For example, an individual report card on diabetes care was developed for all primary care residents; the report card is used as a tool to improve care.
    • Montefiore has spearheaded efforts to create the Bronx Regional Health Information Organization (RHIO) to encourage data sharing among area healthcare organizations.

    Achieving Sustainability

    Despite an exceptionally challenging patient and payer mix, Montefiore Medical Center has been able to achieve financial and organizational sustainability. It has done this by adopting care management processes that allow for integration across the system, by combining traditional and new models of primary care, and by focusing on population health and community accountability.

    Deborah Chase, MPA, is a health policy consultant (dchase@goinet.com).

    This article is excerpted with permission from a longer case study: D. Chase, Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations (New York: The Commonwealth Fund, Oct. 2010). Access the full case study for more details about Montefiore's experiences.