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).

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.