NYSHealth Awards Grant to Reduce Hospital Readmissions in the Bronx

Unique Coalition of Providers and Insurers will Implement Program to Improve Care for Bronx Residents

With a $574,000 grant from the New York State Health Foundation (NYSHealth), a coalition of hospitals and insurers in the Bronx will work together to reduce unnecessary hospital readmissions. The Bronx Collaborative—which includes Montefiore Medical Center, Bronx-Lebanon Hospital Center, St. Barnabas Hospital, Healthfirst, and EmblemHealth—ultimately aims to decrease health care costs, lower inappropriate utilization of services, and improve quality and patient satisfaction.

With a previous grant from NYSHealth, the Collaborative designed a comprehensive program of inpatient counseling and education, and outpatient follow-up for a population of 1600 English- and Spanish-speaking Healthfirst and EmblemHealth members over the age of 50 who are admitted to the medicine service of any of the participating hospitals over a 12-month period beginning in the fall.

Health care costs in the Bronx are 22% above the national average, and spending for inpatient hospital care, which averages more than $12,000 per admission, comprises the largest portion of health care spending.

“Health care costs are increasingly unsustainable. Building on tried-and-true methods, the Bronx Collaborative has developed a care transition model tailored to better serve the challenging medical needs of patients in the Bronx,” said James R. Knickman, President and CEO of the New York State Health Foundation. “The collaborative approach uniquely involves hospitals, insurers, and other providers working together to lower readmission rates and contain costs.”

Several large studies demonstrate that care transitions programs—in which hospital patients are given special counseling on how to manage their health care needs after they are discharged, and receive post-discharge reinforcement through follow-up phone calls or home visits from nurses—reduce readmission rates and improve the health care of patients who receive such services.

Most prior research was conducted within only one hospital, however, and the patients who were followed were less demographically and ethnically diverse than populations cared for by the three Bronx Collaborative hospital systems, whose patient bases overlap. In addition, previous studies did not involve active participation of health insurance companies.

The Collaborative program will feature an innovative reimbursement mechanism that will enable Collaborative members to benefit from lower readmission rates, and will make the program sustainable and replicable. It will use the Bronx Regional Health Information Organization to enable data exchange on patients who use more than one Collaborative hospital, and to share clinical information with primary care physicians and specialists.

“There is strong evidence that patients who are helped with the transition from hospital to home are less likely to be readmitted,” said Stephen Rosenthal, President of CMO, the Care Management Company of Montefiore, whose staff coordinated the development of the project during the planning phase. “With the generous assistance of the New York State Health Foundation, the Collaborative’s Care Transitions Program not only will benefit the initial target population, but also will serve as a model that can be used to reduce hospital readmission rates throughout the Bronx and potentially elsewhere in the City and the State.”

Planning for the program began more than a year ago with support from a previous NYSHealth grant and funding from the New York Community Trust. The Collaborative, which is governed as a not-for-profit organization by a board of senior executives from each participant, envisions adding members in the future and undertaking other projects to improve health care cost-effectiveness and quality.

Bronx-Lebanon Hospital Center serves the South and Central Bronx with two major hospital divisions with a total of 579 beds; a major psychiatric facility; two specialized long term care facilities; and the BronxCare Network of 70 medical practices, including the Dr. Martin Luther King, Jr., Health Center.

Montefiore Medical Center, the University Hospital and Academic Medical Center for the Albert Einstein College of Medicine, provides more than 93,000 inpatient stays a year in its three hospitals with a total of 1,491 beds, and primary and specialty care at more than 100 ambulatory offices, including 22 Montefiore Medical Group locations.

St. Barnabas Hospital, with 466 beds, is located in the heart of the Central Bronx and provides comprehensive inpatient and outpatient services through a network of primary care sites, community mental health centers, dental clinics and a 199-bed skilled nursing facility for long-term and sub-acute care.

EmblemHealth, the company formed by the merger of HIP Health Plan of New York and GHI (Group Health Incorporated) is the largest health insurer in New York State, serving nearly 3.4 million people with over 92,000 providers in 150,000 locations across the tri-state region.

Healthfirst, which is managed by some of the most prestigious hospitals and medical centers in New York, is one of the fastest growing health plans in the State, with over 480,000 members and a network of more than 19,000 providers.

CMO, The Care Management Company, is a subsidiary of Montefiore Medical Center that provides services to health plan members with a staff of more than 300 involved in various aspects of care management and discharge planning, as well as a 100-person customer service call center and divisions handling data analysis, claims payment, provider relations and credentialing.