Population Health Management
Montefiore Care Management offers programs to help people with chronic conditions improve the overall quality of the lives, ensure that they receive care based on the best medical practices, improve their understanding of their condition, and reduce hospital admissions and emergency room visits. Among specialized programs are those for asthma, congestive heart failure, depression, diabetes and hypertension.
Coordinating ongoing treatment for a chronic condition can be a difficult and overwhelming task involving keeping track of multiple doctors’ appointments and organizing a variety of medications. Montefiore Care Management reduces this burden by using a patient-centric approach to care management that spans the entire health care continuum, including hospital care, rehabilitation, outpatient care, professional services, home care, ancillary services, community-based services and remote patient monitoring.
Montefiore Care Management is a valuable resource for patients and families navigating the complexities of the healthcare system. By providing information, care coordination, population health management and health promotion programs, our unique services empower our clients to receive the best possible care and take control of their health. Our methodology focuses on serving the individual as a whole, without being limited to managing a single medical episode or treating a solitary chronic condition on its own.
Our approach to care management stresses the importance of early identification of patients at risk and a collaborative, interdisciplinary team that develops and oversees individualized care plans and promotes patient self-monitoring and education. Our strategy emphasizes the interaction and communication among patients, healthcare providers, case managers, mental health agencies and other allied health professionals.
Our programs provide and reinforce health education, promote compliance with treatment regimens and preventative care guidelines, monitor health status, and promote timely interventions when indicated. We seek to anticipate an individual's healthcare needs, to provide and coordinate the scope of necessary health services and to involve patients in establishing goals and individual care plans. Our involvement spans the full continuum of care: hospital care, rehabilitation, outpatient care, professional services, ancillary support, community-based programs, home care, remote patient monitoring and other services that may be required to return a member to optimum health. Our programs are intended to meet the needs of members with complex and/or chronic illnesses, as well as to maintain the well-being of our healthier members.
Physicians who have an Oxford-UnitedHealthcare or Emblem Health Plan member whom they believe would benefit from Montefiore Care Management's services should call 914-378-6721 to speak to a CMO Case Manager.
Members of Oxford-UnitedHealthcare and Emblem who believe they would benefit from Montefiore Care Management's services should call 914-378-6721 to speak to a CMO Case Manager.
EmblemHealth Dual Eligible Members in Special Needs Plan
CMO has established a SNP Model of Care with the following six goals to provide an appropriate level of care for members of EmblemHealth’s Dual Eligible Special Needs Plan (SNP), for which the CMO has care management responsibility:
- Access to medical, mental health, social services, affordable care and preventive health services
- Coordinated care through an identified point of contact
- Transition of care across health care settings and practitioners
- Appropriate services
- Cost-effective service
- Beneficiary health outcomes
CMO Network Care Management staff support each of these goals through the application of its Utilization Management, Complex Case Management and Care Transitions Programs. EmblemHealth conducts periodic Health Risk Assessments (HRAs) and sends the results to the CMO. CMO then screens the member for the appropriate program referral and intervention. On a monthly basis, the CMO also reviews claims data to identify any SNP members who might be eligible for the CMO Complex Case Management Program and then contacts the member’s PCP and Interdisciplinary Care Team to assist in the development of the care plan.
CMO Network Care Management staff will also monitor the transition of any SNP Dual Eligible members who go from one care setting to another, regardless of whether or not the transition was planned, and will assist with the coordination of care and the communication of the Individualized Care Plan with the PCP and the Interdisciplinary Care Team, as appropriate. EmblemHealth uses specific HEDIS, QARR and CAHPS measures to evaluate the effectiveness of the care SNP members receive. The CMO shares all data related to outcomes measures with EmblemHealth and will know if we have met our goals to improve the health outcomes for this membership by assessing the following outcomes:
- Reduction in A1C
- Member satisfaction
- Maintain low rate of unplanned admissions
- Timeliness of care transition notification of the receiving care setting from the sending setting
Provider education is an integral part of the SNP Model of Care. For more information, you can find EmblemHealth’s SNP Model of Care Training Presentation at:
2016 SNP Model of Care Training
If you need assistance with any of your patients who are EmblemHealth SNP members, call the CMO, Network Care Management Department at 914-378-6722 or Kathleen Byrne, RN, MPH, Senior Director, Network Care Management at 914-377-4762.
University Behavioral Associates (UBA) is Montefiore Care Management’s behavioral healthcare management organization, designed to ensure patients have timely and appropriate access to a full range of mental health and substance abuse services. Using a collaborative care team approach, UBA is committed to providing access to care that spans multiple diagnoses, highly skilled physicians, and specialized health programs which focus on the treatment of both medical and behavioral conditions and risk factors.
UBA provides integrated care management in the following behavioral health areas:
- Addictions/Substance Abuse
- Attention Deficit Hyperactivity Disorder (ADHD)
- Child/Adolescent Issues
- Couples/Marital Counseling
- Eating Disorders
- Grief Counseling
- Life Enrichment
- Family Therapy
- Parenting Skills
- Medication Management
- Relationship Issues
- Stress Management
- Trauma Recovery
- Women's Issues
For more information on UBA:
Call 800-401-4822 or 914-377-4550
Montefiore Care Management's Utilization Management Services are designed to detect under- and over-utilization of services to ensure appropriateness of care while preserving access.
Montefiore Care Management uses a host of information management solutions to make decisions about benefit coverage and medical necessity. When a health plan requires the preauthorization of certain services, Montefiore Care Management conducts a review to determine member eligibility, benefit coverage and medical necessity and appropriateness of the requested services.
Elective admissions that require notification are handled by Montefiore Care Management quickly and efficiently. Review is conducted under the direction of licensed registered nurses and physicians to assess the appropriateness of the inpatient level of care.
Montefiore Care Management has extensive experience in reviewing admissions that result from a member seeking treatment at an emergency facility, as well as concurrent and retrospective reviews of admissions.