By Deborah Chase
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.
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:
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:
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:
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:
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 (firstname.lastname@example.org).
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.
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