Improving Care Coordination and Strategies for Managing Greater Risk and Accountability Montefiore Medical Center

1. 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

2. 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

3. 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

4. The Montefiore Network WESTCHESTER BRONX

5. Highest in risk factors that affect health status in NYS Ethnicity – 80% Minority Economic Factors – 40% in Poverty Percent of Residents - 2006 Percent of Residents - 2006 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..

6. Highest overall morbidity* in NYS Sample Population Health Status Measures Bronx vs. other NYC, NY State and US Averages - 2010 Percent of Residents *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..

7. 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

8. 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 Montefiore IPA and CMO The Montefiore IPA CMO The Care Management Company

9. 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

10. Risk Transfer Arrangements Capitation Savings In 2009: 150,000 Members $750m in Premium Revenue

11. Network Cross-Cutting Function CMO Network Management Acute Care Responsibilities Care Management Activities for payers Network Care Support • 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 Guidance • Chronic Care Management • CHF • Diabetes • Pulmonary • High Cost/Risk • Telemonitoring • Palliative care • Ambulatory EMR • Urgent care access • Medical home model • Call center support • On-site MMG case managers • Patient Education • House Calls • Online Patient Communication (MyMontefiore)

12. 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

14. Population Health Management

15. Care Guidance Patient Management Process

16. Enrollment in CMO Chronic Care Management Programs • 19% of membership is included in a chronic care program Chronic Care Management by Lines of Business Chronic Care Management by Disease State

17. Chronic Care Management: Telehealth Results

18. 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 Pay for PerformanceBronx CHAMPION Program Bronx Community Health and Acute Medical Performance Improvement Organizational Network

19. Bronx Champions: Diabetes MeasuresExternal Comparison Benchmark Data Source: NCQA 2009 State of Healthcare Quality Report (2008 Data)

20. Recent Care Coordination Initiatives CMS Medicare High Cost Beneficiary Demonstration The Bronx Collaborative Patient Centered Medical Homes • - 501C3 Corporation • Includes Montefiore; 2 other Bronx Hospitals;2 Health Plans • -Managing Care transitions • - NYS Health Foundation funding for care transitions -Joint Venture with Bosch Healthcare - Over 6,000 Bronx Medicare FFS members using Telemonitoring -interdisciplinary care teams - 2 pilot sites -40k pts Teaching /nonteaching practices -seeking NCQA certification

21. Clinical Information Systems -EMRs 2.0 million patients 2.0 million patients Accessible Master Patient Index Lifetime Medical Record Master Patient Index Lifetime Medical Record Doctor’s Office and Home 100% MD Order Entry 100% MD Order Entry >600 Expert rules and Decision Support >600 Expert rules and Decision Support Scheduling Scheduling Ambulatory Care Problem List Problem List Rx Pad Rx Pad Care Plans Care Plans Medical Group • Clinical Looking Glass • Data Warehouse • Clinical Research Hospitals

22. HOSPITAL PARTICIPANTS HOSPITAL PARTICIPANTS MontefioreMedical Center Children’s Hospitalat Montefiore Lincoln Hospital Bronx Lebanon Hospital Ctr. Over 85% of the Bronx Providers Sharing Patient Health Information NCB Hospital OTHER PARTICIPANTS Jacobi Medical Center St. BarnabasHospital Quest Labs RX Hub Bronx VA NYC Deptof Health SureScripts Provider Access

23. 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

24. 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 Clinical Indicators & Health Care Initiatives

25. 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

26. 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