improving care coordination and strategies for managing greater risk and accountability montefiore...
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Improving Care Coordination and Strategies for Managing Greater Risk
and Accountability
Montefiore Medical CenterStephen 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 anAccountable 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
BRONX
WESTCHESTER
Highest in risk factors that affect health status in NYS
0
10
20
30
40
50
ChildrenIn Poverty
No HighSchool
Diploma
Bronx
New York City
90th Percentile
Pe
rce
nt
of
Re
sid
en
ts -
20
06
0
10
20
30
40
50
Hispanic Black
Bronx
New York City
US
Pe
rce
nt
of
Re
sid
en
ts -
20
06
Compared to Caucasians, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.
Ethnicity – 80% Minority
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..
Economic Factors – 40% in Poverty
0
10
20
30
Fair or poor health Low Birth Weight Diabetes Asthma
Bronx
NYC
NY State
US 90th percentile
Pe
rce
nt
of
Re
sid
en
ts
Highest overall morbidity* in NYS
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..
*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.
Sample Population Health Status MeasuresBronx vs. other NYC, NY State and US Averages - 2010
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
Formed in 1995 MD / Hospital partnership Contracts with managed
care organizations to accept and manage risk
2,139 physician members– 470 Primary Care
Physicians– 1,669 Specialists
Established in 1996 Wholly-owned subsidiary of
Montefiore Medical Center Performs care
management Delegated by health plans Licensed UR agent and
certified claims adjustors
CMO The Care Management Company
The Montefiore IPA
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
Savings
CapitationPremium
Insurance Company
Provider-Sponsored IPA(Risk Bearing)
MSO
Primary Care HospitalSpecialty Care
▪ Capitation Payments to IPA▪ Savings Delivery System
In 2009: 150,000 Members$750m in Premium Revenue
Acute CareResponsibilities
• Network Care Management Social Work/discharge
planning Utilization Review Documentation
Improvement Patient Navigation
• Contact Center support to hospitalists
• Patient Education• Data Analysis and Reporting• Medical staff and insurance
credentialing
Care ManagementActivities for payers
Network CareSupport
• Care Guidance• Chronic Care
Management CHF Diabetes Pulmonary High Cost/Risk
• Telemonitoring• Palliative care
Network Cross-Cutting Function
• Ambulatory EMR• Urgent care access• Medical home model• Call center support• On-site MMG case
managers• Patient Education• House Calls• Online Patient
Communication (MyMontefiore)
CMONetwork Management
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
Special Programs
Delivery System Offerings
Special Tools & Resources
Chronic Disease Management
Intensive Case Management
SNF Management
Behavioral Care Management
Patient Centered Medical Homes
Urgent Care Center
House Calls Diabetic Nurse Educators
Telemonitoring
Telephonic Support
Pharmacist Review
Case Management System
Palliative Care
Self-IDData
MiningSentinelEvents
MDReferrals
POPULATION
APPLICATION OF SCREENING LOGIC
WELL &
WORRIEDWELL
FUNCTIONALCHRONICALLY
ILL
FRAIL ILL/HIGH UTILIZERS
STRATIFICATION
Population Health Management
Care Guidance Patient Management Process
Interventions Set
Interventions Set
Interventions Set
Interventions Set
Interventions Set
Interventions Set
Interventions Set
Interventions Set
Interventions Set
CUSTOMIZED MEMBER-CENTRIC
CARE PLAN developed/owned by
accountable Care Manager ACCOUNTABLE
CARE MANAGER
CarePlan
BEHAVIORAL CARE
PALLIATIVE/EOL CARE
PHARMACIST REVIEW
SNFMANAGEMENT
MEDICALHOUSE CALLS
TELEMONITORING
CHRONIC CARE MANAGEMENT
COMPLEX CARE MANAGMENT
CMO PROGRAM OFFERINGS with
COORDINATED INTERVENTIONS SETS
Enrollment in CMO Chronic Care Management Programs
19% of membership is included in a chronic care program
63%
17%
20%
Medicare
Medicaid
Commercial 54%
44%
2%
Diabetes
Respiratory
CHF
Chronic Care Management by Lines of Business
Chronic Care Management by Disease State
Chronic Care Management: Telehealth Results
Telehealth Program Members: Medical Costs (All Dx)
$20,594
$11,679
$28,102
$20,668
$7,918
$18,717
$0$5,000
$10,000$15,000$20,000$25,000$30,000
Health Buddy Autolink Telescale
PM
PY
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 PerformanceBronx 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 MeasuresExternal Comparison
Benchmark Data Source: NCQA 2009 State of Healthcare Quality Report (2008 Data)
Recent Care Coordination Initiatives
CMS Medicare High Cost Beneficiary
Demonstration
The BronxCollaborative
-Joint Venture with Bosch Healthcare
- Over 6,000 Bronx Medicare FFS members using Telemonitoring
- 501C3 Corporation
- Includes Montefiore; 2 other Bronx Hospitals;2 Health Plans
-Managing Care transitions
- NYS Health Foundation funding for care transitions
-interdisciplinary care teams
- 2 pilot sites -40k pts
Teaching /nonteaching practices
-seeking NCQA certification
Patient Centered Medical Homes
2.0 million patients
Master Patient Index
Lifetime Medical Record
100% MD Order Entry
Scheduling
Care Plans
>600 Expert rules and Decision
Support Problem ListRx Pad
Clinical Information Systems -EMRs
Doctor’s Office and Home
Ambulatory Care
Medical Group
Hospitals
Accessible2.0 million patients
Master Patient Index
Lifetime Medical Record
100% MD Order Entry
Scheduling
Care Plans
>600 Expert rules and Decision
Support Problem ListRx Pad
Clinical Looking Glass• Data Warehouse• Clinical Research
MontefioreMedical Center
Bronx Lebanon Hospital Ctr.
NCB Hospital
Bronx VA
Jacobi Medical Center
NYC Deptof Health
Quest Labs RX Hub
Provider AccessSureScripts
Lincoln Hospital
HOSPITALPARTICIPANTS
Children’s Hospitalat Montefiore
HOSPITALPARTICIPANTS
St. BarnabasHospital
OTHERPARTICIPANTS
Over 85% of the Bronx Providers Sharing Patient Health Information
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– Smoke free campus– Bronx Breathes– BOLD
• Diabetes– Pediatric Obesity Initiative – B’N Fit– School Health
• Hypertension – CFCC hypertension clinic
• Colorectal Cancer – Psychosocial Oncology Support Program
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