The Care Management Company of Montefiore Medical Center

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).

Under the implementation grant, the Bronx Collaborative tested a care transition demonstration based on nationally recognized evidence-based models, such as Project RED, Project BOOST, and the Coleman Care Transitions Initiative. The Bronx Collaborative’s goal was for 1,600 cases to participate in the care transition demonstration over 12 months.

When the intervention was implemented at full scale, the Bronx Collaborative reached an estimated 9,300 cases at risk of readmission each year, generating an estimated annual net savings of $5.5 million.