The Care Management Company of Montefiore Medical Center

The Care Management Company of Montefiore Medical Center

Grant Status

In Progress

Project Title

Establishing a Bronx Collaborative for Health Improvement: Planning Grant

Award Amount

$75,000

Location

Bronx, New York

Website

http://www.montefiore.org/prof/managedcare/cmo/

Date Awarded

August 17, 2009

Costly chronic care services for poor residents of the Bronx are largely paid for by public health insurance programs, and costs could be reduced by improving post-hospital care to prevent hospital readmissions. The Care Management Company (CMO) of Montefiore Medical Center will establish a Bronx Collaborative of hospitals and insurers to develop a regional model for reducing the rate of hospital readmissions in the Bronx, which are a major driver of health care costs.

Residents of the Bronx are disproportionately affected by chronic conditions such as hypertension, diabetes, obesity, and asthma. These chronic conditions often require frequent and costly hospitalizations, and contribute to elevated per capita health care expenses in the Bronx, which is 22% above the national average. Under this planning grant, CMO will collaborate with the three major hospital systems—Montefiore Medical Center, Bronx-Lebanon Hospital Center, and St. Barnabas Medical Center—and two insurers—HealthFirst and EmblemHealth—to plan for the implementation of a hospital readmission reduction pilot project. CMO will develop the management and financing structure to implement and sustain the Collaborative, identify effective strategies for successful transitions out of hospital care, and evaluate the potential savings and reduction in readmissions. CMO will consider implementing the Care Transitions Program model in which a transition coach helps to smooth the transition from hospital to home or other post-acute setting and hopes to share successful strategies with other hospitals.