Montefiore Care Management Organization at Montefiore Medical Center

Montefiore Medical Center
Bronx, NY
1,418 Beds

The Problem
Montefiore Medical Center is a large, academic medical center in New York City that has created a large integrated system for its low-income patients. The Care Management Organization is a for-profit subsidiary of the medical center, and it receives capitated payments for more than 140,000 patients to provide medical and behavioral care management in addition to traditional health plan administrative functions.

The Solution
The Care Management Organization shares and analyzes its data through an integrated information technology system. All providers within the Montefiore Medical Center and its outpatient locations have access to the same electronic health record system. They utilize a data warehouse, called Clinical Looking Glass, to measure quality of care for this specific patient population and to identify areas for improvement. The Care Management Organization uses clinical data, along with claims data, to identify patients that would benefit from care coordination. Care managers look closely at emergency department visits, as frequent trips can be an early sign of ongoing, complex problems. The Care Management Organization also participates in the Bronx Regional Health Information Organization, which contains data on more than one million patients. The Care Management Organization can utilize the data to check on its patients' interactions with Bronx health providers other than Montefiore. The medical center is in the unique position to mine both provider claims and cost data to understand where care can be improved. All patients have access to an online personal health record to monitor their own care progress. For more complex patients, caregivers have permission to access information from the personal health record.

This case study was originally featured in the HPOE guide: 'Caring for Vulnerable Populations,' published January, 2012.