In December 2011, Montefiore was selected by the federal Centers for Medicare & Medicaid Services (CMS) as one of 32 health care organizations in the country (and the only one in New York State) to participate in the Pioneer Model Accountable Care Organization Program.
Accountable Care Organization (ACO) is a term that is applied to a group of health care providers—hospitals, primary care and specialist physicians and allied health professionals—who cover the entire care continuum and agree to work together and accept collective accountability for the cost and quality of care delivered to patients.
The goal is to achieve what CMS calls the Three Part Aim:
- Improving the experience of care for individuals, improving the health of populations and lowering per capita costs.
The Pioneer ACO Program was designed for delivery systems with extensive care improvement experience and experience with payment arrangements that include financial accountability and performance incentives.
The program requires Montefiore to meet 33 separate quality and patient satisfaction measures and lower the costs to the Medicare program for a population of 23,000 beneficiaries of the regular, fee-for-service Medicare program who have received at least some of their care from approximately 2,400 physicians employed by or affiliated with Montefiore.
Transitioning from a fee-for-service orientation to an outcomes-based model like the Pioneer ACO requires effective care management programs. Montefiore began preparation for the transformation of health care delivery in the Bronx 16 years ago when it formed CMO, Montefiore Care Management, to offer care coordination services to members of health plans. CMO currently provides medical and behavioral health care management services for more than 200,000 members of health plans with Medicare Advantage, Medicaid Managed Care and commercially-insured programs under capitation and other value-based purchasing contracts.
The Care Guidance Program is the centerpiece of Montefiore’s care coordination efforts. The Care Guidance Program utilizes physician referrals and established Health Information Technology (HIT) and Health Information Exchange (HIE) infrastructure to identify high-risk individuals. Once identified, outreach is initiated and a comprehensive biopsychosocial assessment is conducted.
Upon completion of the assessment, the beneficiary is assigned an Accountable Care Manager (ACM) who is a nurse or social worker. The ACM develops a personalized plan of care for the beneficiary that may include interventions and resources such as chronic care management programs; medication reconciliation, adherence and optimization by CMO pharmacists; linkage to community support services and entitlement programs; behavioral health management; life care planning and advanced illness management; inpatient care monitoring; care transitions management; and caregiver support.