Expanding Health Care Coverage

Grantee Name

Care Management Company of Montefiore Medical Center

Funding Area

Expanding Health Care Coverage

Publication Date

December 2015

Grant Amount


Grant Date:

August 2009 – January 2013


The Bronx is home to 1.4 million New Yorkers, many of whom face some of the most challenging health problems in the State.

A disproportionate number of Bronx residents suffer from chronic illnesses, such as diabetes, obesity and asthma—leaving them susceptible to frequent and costly hospitalizations. Research indicates that some of these health care costs, most notably readmissions, could be avoided with timely and appropriate post-hospital care. In 2009, NYHealth awarded the Care Management Company of Montefiore Medical Center (CMO) a planning grant to develop a regional model for reducing the rate of hospital readmissions and associated costs in the Bronx.

In 2010, NYHealth awarded CMO a second grant to implement and test this model: the Bronx Collaborative Care Transitions Program (Care Transitions Program).


Outcomes and Lessons Learned

  • Developed a partnership among Montefiore Medical Center, Bronx-Lebanon Hospital Center, and St. Barnabas Hospital health systems and insurers Healthfirst and EmblemHealth;
  • Implemented the Care Transitions Program at participating hospitals;
  • Identified 5 key factors that reduced the likelihood of a hospital readmission within 60 days; and
  • Reduced 60-day readmission rates by nearly 40% for participants who experienced two or more program interventions.