Hospitals in pursuit of excellence

Integration for Coordination

Care coordination is challenging for complex and vulnerable patient populations. Montefiore Medical Center in Bronx, New York, has focused on integrating information systems to improve care for its primarily low-income patients. This large, nonprofit, academic medical center created the Care Management Organization (CMO), a for-profit subsidiary that receives capitated payments for about 140,000 patients to provide medical and behavioral care management and other administrative functions. All providers within the medical center and its outpatient locations have access to the same EMR and use a data warehouse. CMO uses the clinical data and claims data to identify patients who would benefit from an extensive level of care coordination. CMO also participates in the Bronx Regional Health information Organization?with data on more than 1 million patients?to check patients? interactions with other Bronx health providers. All this integration helps Montefiore understand where patient care can be improved. Patients themselves can access an online personal health record to monitor their care.