A Montefiore care manager talking to a patient (Photo: Montefiore Medical Center)

You wake up, brush your teeth, check your weight on the scale, and the telephone rings. A care manager is on the line. Your weight has spiked since the last reading. That could have an impact on whether your diabetes is still under control. The manager guides you through the use of other measuring devices which, like the scale, are electronically wired to the monitoring center. Your medical team springs into action.

“Team” is the key word at the Montefiore Medical Center’s new Pioneer Accountable Care Organization (ACO) in the Bronx. Pioneer is one of 32 programs around the country chosen by Medicare to test the idea that teamwork can save both lives and money, easing a huge burden on the finances of the national program that insures seniors’ health.

“This may sound somewhat ironic coming from a hospital, but one of the things we are trying to do is keep people out of the hospital”

If the idea works, Montefiore will prosper, too – because Medicare will share the money it saves with the medical centers that save it.

“We believe we can not only improve the health status of the beneficiaries, but lower their costs,” said Steven Matthews, a member of the Pioneer project team. “To the extent we lower the costs, we will share in those savings.”

As a health network responsible for 150,000 lives in the Bronx, Montefiore has practiced team medicine for years. As host of one of the new ACOs, a concept encouraged by the Obama healthcare reforms, Montefiore’s teamwork will be put on national display.

The stakes are huge. Medicare has gone into the red by running a fee-for-service program. That is, every time you contact a healthcare provider, Medicare pays a fee. The new idea is to generate fewer of those fees. Coordinated care by a team of healthcare providers should keep people healthy enough to avoid a lot of fees. The team gets compensated for keeping its clients healthy.

“This may sound somewhat ironic coming from a hospital, but one of the things we are trying to do is keep people out of the hospital,” Matthews said. “It’s essential to staying as healthy as you can be.”

The Bronx ACO will serve 24,000 Medicare patients who already have relationships with Montefiore’s 2,400 in-house or community-based physicians.

From a patient’s perspective, specialized help is never far away. The ACO will help you monitor your condition at home, will make your doctors’ appointments, and will get you to the doctor on time. The doctors themselves will be able to see all of your records, including those of the specialists and other caregivers involved with your case.

The idea is to keep patients healthy enough to avoid trips to the emergency room – and avoid hospital stays that cost an average of more than $10,000 per patient. If you do end up in the emergency room, the ACO will be notified and one of its nurses will meet you there to manage your care -  possibly in a less urgent setting, like a doctor’s office.

When you’re discharged, a pharmacist will make sure you fill your prescriptions, and the ACO will make sure you take your pills. Other healthcare workers will counsel you and your family on exercise, diet, and other ways to manage your wellbeing.

Telemonitoring is one of the techniques. Scales and devices to measure blood pressure and – in the case of diabetes patients – sugar levels are monitored remotely. If problems show up, ACO care managers get on the phone and set up an appointment – or, if the patient can’t travel, send a doctor on a house call.

Telemonitor (Photo: Montefiore Medical Center)

Many of Montefiore’s patients need the extra help. As a Bronx institution, the medical center serves one of the city’s most health-challenged populations. The borough has a disproportionate number of chronically ill people suffering from asthma, heart disease and other disorders. Diabetes alone affects 12 percent of the residents of the Bronx, compared to 9 percent in New York City as a whole.

A disproportionate number of Bronx residents also rely on public assistance – a key reason the Obama administration decided to locate one of its first experiments in medical teamwork there. If the idea can cut costs and improve healthcare in a place like the Bronx, it should work anywhere.

“If you can keep people out of the hospital, keep them from coming back to the hospital, make sure they are getting the tests they need, and not those they don’t need, and make sure they are getting the tests only once, instead of multiple times by multiple physicians,” said Matthews,  “you save money.” And lives.

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