Montefiore Medical Center’s Regional Nursing Home Collaborative: Innovations in Post-Acute Care Transitions and Reductions in Readmissions

Resource ID Posted Format
549 September 14, 2012 Reference
Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine


Montefiore Medical Center’s (Montefiore) Care Management Organization (CMO) initiated a unique collaboration with five of the community’s skilled nursing facilities (SNFs) that serve the highest volume of Montefiore patients, with the goal of reducing avoidable readmissions of patients discharged from the acute care setting to a SNF. The objectives of the collaboration were to increase knowledge of evidence-based guidelines, improve communication between acute and post acute providers, improve the quality of care and quality of life for patients, and reduce preventable acute care readmissions. The impetus for establishing the program stems from several factors:

  1. Montefiore patients affected by this program are cared for under a global payment structure, which holds Montefiore financial liable for the health outcomes of patients.
  2. Montefiore patients face complex social challenges in their communities, and require more from their providers that just excellent inpatient care to ensure they remain healthy.
  3. Medicare’s program to reduce payments for avoidable readmissions went into effect in 2012.
  4. Montefiore experiences higher than average incidence of readmissions.
  5. The Bronx has 43 SNFs with approximately 12,000 beds. Montefiore contributes 8,000-10,000 discharges to SNFs annually.
  6. Research findings confirmed higher rates of readmissions by Montefiore patients residing in SNF’s.

*2012 Readiness for Reform (R4R) Innovation Challenge


  1. Facilitate and support the training of geriatrics fellows within the Einstein-Montefiore Geriatrics Fellowship Program by providing exposure to innovative programs both within the geriatric inpatient setting and the post-acute care SNF setting.
  2. Improve care for patients by leveraging research findings produced by Einstein to identify gaps in care at Montefiore and among SNFs in the Bronx Community.
  3. Establish new best practices in care management and communication that are immediately folded into programs for medical students, residents, and fellows training in internal and family medicine and geriatrics, as one mechanism to meet ACGME requirements for the Next Accreditation System (NAS), to prepare graduates for the “future” health care delivery system.


  • 2012 Readiness for Reform (R4R) Innovation Challenge, Care Transitions, Nursing Home/Skilled Nursing Facility, Cross-Institutional Provider Collaboration, Best Practices, Knowledge Transfer, Readmissions, Advanced Care Planning, Geriatrics

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