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					  Improving Care Coordination and
Strategies for Managing Greater Risk
         and Accountability

        Montefiore Medical Center
Stephen Rosenthal, President/CEO CMO Care Management Co.,
              Corporate VP, Network Management
    Anne Meara, Associate VP, Network Care Management
Nicole Hollingsworth, Director Community and Patient Education
          Moving Toward an
     Accountable Care Organization
• Overview of Montefiore Medical Center
• Our experience with capitation
• Care Management and Managing care-
  not price
• The Delivery System and the Patient
  Centered Medical Home
• Community Health and Promotion
                 Challenges
   Bronx Location – 1.4 million residents
   Poor, disadvantaged population
   Over 75% government payer/90% Bronx/So.
    Westchester
   High hospital use rates associated with
    disease prevalence, demographic and
    socioeconomic factors
   History of low margins, low liquidity, high
    leverage in NYS/ NYC
       The Montefiore Network

WESTCHESTER




     BRONX
                   Highest in risk factors that affect health status
                                        in NYS

                                Economic Factors – 40% in Poverty                                                   Ethnicity – 80% Minority
  Percent of Residents - 2006




                                                                               Percent of Residents - 2006
                                 50                          Bronx                                           50                      Bronx
                                 40                          New York City                                   40                      New York City

                                 30                                                                                                  US
                                                             90th Percentile                                 30
                                 20
                                                                                                             20
                                 10
                                                                                                             10
                                  0
                                                                                                              0
                                       Children    No High
                                                                                                                  Hispanic   Black
                                      In Poverty    School
                                                   Diploma
                                                                                      Compared to Caucasians, these minority groups
                                                                                      have higher incidence of chronic diseases, higher
                                                                                      mortality, and poorer health outcomes.

Sources: 2010 County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute;
www.counthealthrankings.org/new-yor.com ;Community Health Profiles, NYC Dept of Health and Mental Hygiene, 2006..
                Highest overall morbidity* in NYS
                                                  Sample Population Health Status Measures
                                                Bronx vs. other NYC, NY State and US Averages - 2010



                                       30                                                            Bronx
               Percent of Residents




                                                                                                     NYC

                                       20                                                            NY State

                                                                                                     US 90th percentile

                                       10



                                         0
                                              Fair or poor health   Low Birth Weight     Diabetes            Asthma

                                      *Morbidity defined as: Poor or fair health, low birth weight, poor physical and mental health days.
                                      Low birth weight is defined as <2,500 grams (5.5 pounds). Target is 90% percentile of U.S. Counties.


Sources: 2010 County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute;
     www.counthealthrankings.org/new-yor.com ;Community Health Profiles, NYC Dept of Health and Mental Hygiene, 2006..
           Montefiore’s Resources
 Delivery System Attributes:
  − Experience managing the care of defined populations

  − A broad, community-based primary care and specialty network

  − An IPA with 2139 employed and voluntary physicians

  − A large Home Health Agency

 A robust health information infrastructure that
  supports clinical decision making, patient to
  provider and provider to provider
  communication and workflow automation
 A Care Management Organization
           Montefiore IPA and CMO
                                         CMO
    The Montefiore IPA
                              The Care Management Company

 Formed in 1995               Established in 1996
 MD / Hospital partnership    Wholly-owned subsidiary of
 Contracts with managed        Montefiore Medical Center
  care organizations to        Performs care
  accept and manage risk        management
 2,139 physician members      Delegated by health plans
   – 470 Primary Care          Licensed UR agent and
     Physicians                 certified claims adjustors
   – 1,669 Specialists
Montefiore’s Managed Care Strategy

 Growth and increased market share
 Expertise in managing risk
 Incentives and enablers to improve performance
    Creation of a large, aligned internal “customer”
 Creation of new capacities
    Montefiore’s “R and D” arm
 Operation of key “shared services” for MMC
    Achieving scale in key areas
          Risk Transfer Arrangements
                                 Capitation
                                     Premium




                                 Insurance Company




                                  Provider-Sponsored IPA
                                       (Risk Bearing)


                           MSO
Savings

            Primary Care           Specialty Care          Hospital




                 ▪ Capitation Payments to IPA
                 ▪ Savings       Delivery System
                        In 2009: 150,000 Members
                       $750m in Premium Revenue
                Network Cross-Cutting Function
                                   CMO
                            Network Management


        Acute Care               Care Management            Network Care
      Responsibilities          Activities for payers         Support

• Network Care Management       • Care Guidance         • Ambulatory EMR
     Social Work/discharge     • Chronic Care          • Urgent care access
       planning                   Management            • Medical home model
     Utilization Review             CHF               • Call center support
     Documentation                  Diabetes          • On-site MMG case
       Improvement                   Pulmonary           managers
     Patient Navigation             High Cost/Risk    • Patient Education
• Contact Center support to     • Telemonitoring        • House Calls
  hospitalists                  • Palliative care       • Online Patient
• Patient Education                                       Communication
• Data Analysis and Reporting                             (MyMontefiore)
• Medical staff and insurance
  credentialing
               Care Guidance

 Assists members with complex medical and
  psychosocial needs
 Patient-centric, not just managing a medical episode or
  a chronic condition
 Facilitates communication and care coordination
  amongst health care providers
 Addresses polypharmacy and non-compliance with
  medication regimen
 Helps resolve care access issues
 Promotes member self-management
          Care Management Tools

 Behavioral Care                                          SNF
  Management          Special Programs                 Management
                   Chronic Disease    Intensive Case
                    Management         Management


 House Calls    Delivery System Offerings                Diabetic Nurse
                                                           Educators
                 Patient Centered      Urgent Care
                 Medical Homes           Center

Pharmacist     Special Tools & Resources                Telemonitoring
  Review
               Case Management       Telephonic   Palliative Care
                    System            Support
Population Health Management
                         POPULATION



                      Data            Sentinel     MD
    Self-ID
                     Mining           Events     Referrals




              APPLICATION OF SCREENING LOGIC

                      STRATIFICATION




                               WELL
                                &
                              WORRIED
                               WELL




                           FUNCTIONAL
                          CHRONICALLY
                               ILL
                             FRAIL ILL/
                          HIGH UTILIZERS
Care Guidance Patient Management Process
                                                      CMO PROGRAM OFFERINGS
                                                                with
                                                     COORDINATED INTERVENTIONS
                                                               SETS

                                                          COMPLEX CARE
                                                           MANAGMENT


   Interventions Set                                      CHRONIC CARE
                                                          MANAGEMENT
   Interventions Set

   Interventions Set


                                        Care            PALLIATIVE/EOL CARE
                                        Plan
                       CUSTOMIZED
                         MEMBER-
                          CENTRIC
                        CARE PLAN                        BEHAVIORAL CARE
                         developed/
   Interventions Set
                          owned by
                        accountable                           SNF
   Interventions Set                  ACCOUNTABLE
                       Care Manager                        MANAGEMENT
   Interventions Set
                                      CARE MANAGER


                                                             MEDICAL
                                                           HOUSE CALLS



                                                        PHARMACIST REVIEW
   Interventions Set

   Interventions Set

   Interventions Set                                     TELEMONITORING
     Enrollment in CMO Chronic Care
         Management Programs
 19% of membership is included in a chronic care
  program
 Chronic Care Management by Lines of       Chronic Care Management by Disease
              Business                                    State

                                                       2%
         20%




                                                                        Diabetes
                              Medicare
                                                                        Respiratory
                              Medicaid       44%
                                                                        CHF
                              Commercial                          54%
   17%
                        63%
Chronic Care Management: Telehealth Results

                                 Telehealth Program Mem bers:
                                     Medical Costs (All Dx)

                                                                                 $28,102
            $30,000
            $25,000       $20,594                                                          $20,668
                                 $18,717
            $20,000
     PMPY




            $15,000                                  $11,679
                                                           $7,918
            $10,000
             $5,000
                 $0
                           Health Buddy                   Autolink                  Telescale

                      1 Yr Pre Program Enrollment*        1 Yr Post Program Enrollment*

  *Only includes members who enrolled in a telehealth program between 2003-2008. Autolink is used for
  diabetes, telescale for CHF and Health Buddy CCM diabetes and/ or CHF patients
                      Pay for Performance
                 Bronx CHAMPION Program
     Objective: improve quality of care for diabetes /
      cardiovascular disease
     Manage risk factors
     Standardized measures
        –   Clinical care
        –   Patient satisfaction
        –   IT system use
        –   Utilization
     Provider Participation
        – 140 community based IM and FP providers
        _ $2m incentive payments

Bronx Community Health and Acute Medical Performance Improvement
Organizational Network
Bronx Champions: Diabetes Measures
                      External Comparison




 Benchmark Data Source: NCQA 2009 State of Healthcare Quality Report (2008 Data)
     Recent Care Coordination Initiatives


     CMS Medicare
                                  The Bronx           Patient Centered
  High Cost Beneficiary
                                 Collaborative         Medical Homes
     Demonstration



-Joint Venture with           - 501C3 Corporation
                                                      -interdisciplinary care
 Bosch Healthcare             -Includes Montefiore;   teams
                              2 other Bronx
- Over 6,000 Bronx Medicare                           - 2 pilot sites -40k pts
                              Hospitals;2 Health
  FFS members using           Plans                     Teaching
  Telemonitoring                                      /nonteaching practices
                              -Managing Care
                              transitions             -seeking NCQA
                                                      certification
                              - NYS Health
                              Foundation funding
                              for care transitions
Clinical Information Systems -EMRs
     Accessible
                                 2.0 million patients

                                   Master Patient Index
                                 Lifetime Medical Record


 Doctor’s Office and Home




                                  100% MD Order Entry

                            >600 Expert rules and      Scheduling
     Ambulatory Care          Decision Support
                                                    Problem List
                                 Rx Pad
                                               Care Plans




      Medical Group

                                  Clinical Looking
                                  Glass
                                  •Data Warehouse
                                  •Clinical Research

        Hospitals
                                                                             HOSPITAL
     HOSPITAL                                                              PARTICIPANTS
   PARTICIPANTS
                                                                             Montefiore
 Children’s Hospital                                                        Medical Center
   at Montefiore




                                                                            Lincoln Hospital
   Bronx Lebanon
    Hospital Ctr.
                               Over 85% of the Bronx Providers
                               Sharing Patient Health Information

                                                                     NCB Hospital
                                         OTHER
Jacobi Medical Center                 PARTICIPANTS

                                                                                    St. Barnabas
                                                                                      Hospital
                        Quest Labs                        RX Hub
      Bronx VA


                                         NYC Dept
                                         of Health
                        SureScripts                     Provider Access
 Managing Risk and Community Interaction

• Identify high prevalence clinical indicators and
  match with community interventions provided to
  targeted populations
• Identify, sponsor and implement at-scale
  community level health promotion activities
• Implement community educational initiatives to
  demystify the healthcare experience and to
  inform on appropriate healthcare utilization
 Clinical Indicators & Health Care Initiatives

• Smoking               • Hypertension – CFCC
  – Smoke free campus     hypertension clinic
  – Bronx Breathes
  – BOLD                • Colorectal Cancer –
                          Psychosocial
• Diabetes                Oncology Support
  – Pediatric Obesity     Program
    Initiative
  – B’N Fit
  – School Health
Scaled Community Health Promotion Initiatives

 • Tour De Bronx
   – mobilizes over 5,000 riders across the Bronx
 • Bronx on the Move
   – Car Free Streets Partnership with DOT, NYC Parks
     and Transportation Alternatives to instruct and
     encourage exercise in public spaces
 • NYRR/ Empire/ Montefiore Partnership: Kids
   Run for Kids
   – Municipal/Civic/Corporate NGO partnership with
     Bronx Schools encouraging fitness and community
     service
    Community Education Initiatives

• Westchester SOS Program
  – Senior Initiative providing 280 annual educational
    sessions annually across 10 sites
• Health Screenings and Educational Sessions
  – Teddy Bear Hospitals
  – Community Diabetes Screening
• Farmer’s Markets/ Green Carts
  – Training partnership with Monroe College to assist
    vendors with business and customer service practices

				
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