"These are all elements of a successful ACO, and our experience over the years ideally positioned Montefiore to be invited to participate in the Pioneer ACO model," said Chung.

Montefiore is breaking away from the traditional, fragmented care model to create a superior academic health system that is efficient, effective and designed around the patient. Patients in Montefiore's ACO programs are routinely reviewed for potential high-risk and vulnerability factors and those identified are offered interventions and programs designed to improve their conditions. A range of interventions based on the patients' needs are offered at Montefiore, with a goal of keeping patients healthy and out of the hospital.

"For example, patients with congestive heart failure can be connected to intensive care management services, including the use of home monitoring devices and pharmacist interventions to ensure medication compliance, to help prevent readmissions and keep them at optimal health," Chung said.

In the first year of the Pioneer ACO, Chung said Montefiore learned and proved that the accountable care model works — even within one of the most economically- and health-challenged communities in the country.

Future plans

Going forward, Montefiore's focus remains on ensuring its ACO beneficiaries receive the right care, in the right place, at the right time, and have access to Montefiore's care coordination services, if needed.

Montefiore will also continue efforts to expand its ACO network by engaging like-minded providers throughout the region. In 2013, Montefiore brought on new partners from the Bronx, Brooklyn and Staten Island. In 2014, it aims to expand its network in the Bronx and Brooklyn.

"As we expand, we will continue to focus on the importance of EMR adoption among community physicians in order to further accelerate care coordination and joint quality improvement activities," said Chung.

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