Coordination of care services is no longer playing by old school health system rules. By stepping away from fee-for-service medicine and toward the pay-for-performance model, Montefiore is continuing to transform the delivery of optimal patient care. New data from the government’s Next Generation Accountable Care Organization (ACO) Model reaffirms that this patient-centered approach to care improves health outcomes and contains rising expenses.

“Almost 5,000 independent physician practices and providers from hospitals across New York, including Montefiore, participate in our progressive care management model through the Next Generation ACO,” said Dr. Andrew D. Racine, system senior vice president and chief medical officer, Montefiore, and professor of Pediatrics, Albert Einstein College of Medicine. “With more data than ever before, we’re able to pinpoint how to most efficiently improve patient care at every touch point – whether it is in the primary care setting, hospital or home.”

Identifying new technologies that complement traditional doctor visits is one way Montefiore has seen success. For example, digital cameras are now placed in local doctors’ offices to screen for diabetic retinopathy during routine check-ups. This means that patients do not need multiple visits, first with a primary care doctor, and then with a specialist to get comprehensive diabetes exams. The exam is virtually sent to specialists who review the digital photography and then send test results back to the primary care providers in as little as two hours. The decrease in the number of doctor’s appointments, combined with the efficiency of getting eye exam results back quickly, has led to increased satisfaction and a decrease in cancelled primary care appointments.

Other innovations are aimed at improving care for patients with chronic kidney disease (CKD). CKD, which causes kidneys to gradually lose function, affects 26 million adults in the United States, including more than 100,000 Bronx residents. The total annual medical costs attributable to stage 2 through stage 4 CKD among the Medicare fee for service beneficiary population is almost $49 billion.

Kathleen Byrne, RN, MPH, assistant vice president, Montefiore’s care management organization, oversees more than 200 staff including social workers, pharmacists, and care managers who are certified in case management, and specialize in areas like CKD.

“The role of our nurse care managers is to be the ‘gap plan’ for all of our patients ~ patients go to primary care, they go to the hospital, but there’s everyday life in between,” said Byrne. “Our patients suffering from CKD often have multiple illnesses and experience a lot of anxiety over basic things, like eating pizza, for example, which could lead to fluid in their kidneys, and require an emergency dialysis. But we’re there for them. Our role is to provide those rescue phone numbers so patients always have someone to speak with. We then provide support to guide them through the healthcare system and make sure they get the resources they need.”

In addition to the wraparound care management support, Montefiore embedded technology in more than 40 community practices throughout the Bronx so providers can receive real-time alerts if their end stage renal disease patients arrive at Montefiore hospitals. The technology plus insights from care managers helps providers and patients have more conversations about their care, ensuring patients can get dialysis in the most appropriate care setting. In the past year, this comprehensive effort has led to a 50 percent decrease in Montefiore hospital admission rates for Medicare patients with chronic kidney disease, reducing healthcare costs.

“We are working across care settings to change how healthcare is delivered,” said Stephen Rosenthal, senior vice president, Population Health Management, Montefiore. “With Montefiore’s care management organization as the backbone, we’re lining up transportation, technology, and homecare resources that are keeping patients healthier. At the same time, we’re getting more data than ever before, which we’re delivering to community providers, so together we can provide the highest quality care for patients, get to know them as individuals, and begin to focus more on preventing sicknesses rather than treating them.”

Montefiore affiliated providers under the Next Generation model scored approximately 20 percent higher than other Next Generation participants in preventive health screenings, such as those for breast and colorectal cancer, and helping people take the appropriate medications at the right time.

More than 43,000 Medicare beneficiaries are in Montefiore’s Next Generation ACO. Montefiore’s leadership under the Next Generation ACO has led to $15.2 million in Medicare savings.