Stephen Rosenthal and John Williford talk about the approach of the Montefiore health system, and why their integrated approach to health care has been so successful.
- SR: Stephen Rosenthal
- JW: John Williford
SR: Well the Montefiore health system is really a culture and it’s been born of many years of social mission.
JW: We’ve been doing this for 22 years and we’ve had a lot of experience in determining what causes people to have adverse reactions or adverse outcomes.
SR: Most of the time the doctors do a very good job. The real challenges are the things that happen after that experience, because they’re only with the physician for 15 minutes but they’re in their life for the rest of the time.
JW: We really view ourselves as community partners and serving the people that are in the community with us and so through that we’ve developed programmes that deal with all the social determinates of health.
SR: We had to build the primary care network where none existed before because as an academic environment you tend to be speciality orientated and in order to do population health, you need to be primary care-focused.
JW: We identified those that are the most vulnerable and most complex. We assigned them an accountable care manager who then does an assessment of their social as well as their clinical needs and we involve them with a care team to surround them to help them through the difficulties of navigating the healthcare system and really become like managers for that patient population.
SR: The most rewarding aspect of it, for me personally, has been our ability to intervene in individuals who have little or nothing, and who are challenged by just the day and being able to provide them opportunities at improvement in health, managing their substance and mental health issues, whereas there would be no-one else to care for them in the community.
JW: We look at all their social needs, whether it’s food insecurity, housing instability etc., and through that process we develop a life plan and it identifies goals in conjunction with our member or patient and through those goals we identify any barriers and interventions that need to be done and that is managed in conjunction with the patient with their care team.
SR: You have to listen to the issues that are going on within the community that you’re servicing and if a patient doesn’t have a stable home environment to go to after they’ve been in a hospital for whatever reason, it’s our responsibility to make sure they’re going to a safe environment when they leave our hospital. So we have to partner with the community to make sure that we’ve created those safe environments.
JW: We stratify our community-based partnerships so that we are directing the right patients to the right partner. So for example, if we have an end stage renal disease patient and they need a low sodium diet, we want to make sure that they’re getting referred to a food bank that is going to provide low sodium meals.
SR: Involvement in the community is a multifaceted approach but we have actually an entity within our organisation that is called our community population team and they actually work in the various communities, usually around the primary care hub and they work with the individuals who live in those communities around their special needs.
SR: We have a great deal of diversity amongst multiple different ethics and populations from all over the world and so in those communities they deal with their special issues on healthy eating, on creating opportunities for them both in terms of work opportunities, as well as just shelter and community engagement.
JW: We’ve learnt that we have to meet the member, the patient, the citizen, wherever they are, that if we don’t meet the patient where they are in their life journey, we’re not going to be successful in managing the total cost of care. So someone who has housing insecurity isn’t really worried about losing weight or obesity, if they’re worried about where they’re going to live or sleep tonight.
SR: So my advice for someone trying to start a model of care similar to ours, is to emulate those things that have already been successful, so work with organisations like ours and others around the world where there have been proof of concept and that all that we do is doable by everyone.
JW: You can start with high utilisers, you can start with people that you’ve identified set social needs, but you really should start that immobilisation that’s not going to help you get to where you need to be to really get into population health.