Most of the 126 academic medical centers (AMCs) in the United States are located in urban communities, many in inner-city neighborhoods where residents living in the very shadow of these institutions lack access to basic health care and experience high rates of common diseases and other medical problems. In many of these neighborhoods, the AMC is the only entity with the professional expertise, the management strength, and the physical and financial resources necessary to improve the population's health. Yet AMCs tend to take a narrow view of their social responsibility. They treat the sick who find their way through their doors. They produce superbly trained professionals who will do the same, and through their research they expand the base of knowledge about their patients’ diseases. But AMCs have not, for the most part, declared themselves responsible for the communities around them and dealt in a systematic way with the major problems affecting health in those communities.
I have argued1,2 that medical schools and their primary teaching hospitals have an affirmative obligation to go beyond the classic triad of the AMC mission—patient care, teaching, and research—to build community-based systems of care that are capable of improving the health of underserved populations within their reach. That obligation derives, in part, from an implicit social contract that requires AMCs, in exchange for large amounts of public financial support, to accept responsibility for addressing many of society's pressing problems, including the complex conditions that undermine health in many inner-city neighborhoods. This obligation derives also from ideas of social justice, which require a society's members to provide for those in their midst who are disadvantaged and in need. Finally, there are the pragmatic arguments of proximity and resources. If AMCs, situated within reach of communities in need and singularly equipped to help, do not undertake that responsibility, who will?
The notion that AMCs have a broad social responsibility is not new. Calls to action along these lines have been made for more than 50 years,3–5 but they have produced little progress in the face of competing priorities, the very real financial pressures on AMCs, and the sheer difficulty of changing established behaviors. There are exceptions, and Montefiore Medical Center is one. Its experience in building a community-based care system for a large urban population is described here, in the hope that it may guide other AMCs to move in a parallel direction.
Montefiore as Case Study: Building a Community-Based Care System
Montefiore Medical Center is the university hospital and AMC for the Albert Einstein College of Medicine. The Montefiore delivery system consists of two general hospitals and a children's hospital (1,062 beds in total), dozens of ambulatory care sites, skilled nursing and rehabilitation facilities, and a large home health agency. In 2004 this system will treat 57,000 inpatients, deliver 4,000 babies, and provide care for 2 million outpatients, including 175,000 emergencies.
Montefiore serves primarily the 1.3 million residents of the Bronx, New York, one of the most economically distressed communities in the nation. Although much of the borough has made a dramatic comeback since the 1960s and 70s, many of its residents still face overwhelming problems. Thirty percent of the population, and more than 40% of children under 18, are below the poverty level. More than half of the population is uninsured or on Medicaid. The population is composed predominantly of groups that have been historically disadvantaged. About one-third of Bronx residents are African American and half are Hispanic. Nearly one-third of the population was born outside the United States, and more than half speak a language other than English at home. The Bronx has higher-than-average rates of many common health problems—asthma, diabetes, heart failure, and cancers—as well as high rates of HIV infection, AIDS, tuberculosis, and substance abuse. Often these conditions are made worse by the harsh conditions of people's lives and the obstacles they face to receiving needed care.
Montefiore has historically taken a very broad view of its role in this community. It has a long record of taking services beyond its own walls and creating programs that go beyond the traditional medical mission.6 Montefiore views service to the community as one of its cardinal commitments and explicitly names it with patient care, education, and research as the fourth tenet of its mission. That commitment has produced an extraordinary range of community services, but they often operated independently of one another, without benefit of interaction and coordination. Beginning in the mid-1980s, Montefiore decided to take its commitment further, by forging the connections necessary to build a truly integrated system of community-based care, expanding it as needed and supporting it with substantial investments. In expanding its portfolio of community services, Montefiore has used publicly available data to identify and target its interventions to respond to specific, high-impact health problems and to the needs of particularly high-risk and underserved populations in its community. Next I describe some of the initiatives that Montefiore undertook to create that system.
Expanding the Primary Care Network
The beginnings of Montefiore's community-based primary care system go back to the 1960s, when Montefiore created one of the first federally designated neighborhood health centers. By the mid-1980s, Montefiore was operating three such centers in the Bronx. They were caring for tens of thousands of patients, but there remained a huge unmet need for high-quality, easily accessible care. Studies by the regional and state planning agencies identified a series of health crisis zones in the Bronx, in which physician/population ratios and admission to hospitals for ambulatory care–sensitive diagnoses were particularly poor. Montefiore responded to this need by expanding and reorganizing its base of in-community primary care centers into a single system of primary care, reaching into the very poorest neighborhoods in the Bronx. This was a fast-paced expansion, which over the ensuing decade resulted in the development of 22 new primary care centers and new primary care programs reaching into public schools, methadone clinics, homeless shelters, and other sites where care would reach groups in need.
The result is one of the largest networks in the country, with 300 primary care physicians. At its center is Montefiore Medical Group, which today provides more than 750,000 outpatient visits annually and a wide range of programs serving high-risk and high-need populations. Following are some examples of the network's programs.
* The Montefiore School Health Program, the nation's largest school-based primary care program, reaches 15,000 children in 12 elementary, middle, and high schools (including one for pregnant teenagers).
* The New York Children's Health Project delivers primary care to thousands of homeless children from mobile pediatric units that make more than 12,000 visits annually.
* The Montefiore Substance Abuse Treatment Program, an integrated program of medical care, mental health service, and substance abuse treatment, annually provides more than 200,000 methadone visits and nearly 8,000 primary and specialty care visits to a population of 1,000 opiate-dependent individuals.
The primary care network is supported by and integrated with the full inpatient and specialty services of Montefiore. The specialty back-up and other supports of the medical center and the connection to an academic community have been key to the network's growth and success. Without these resources, it would not have been possible to attract and retain professionals to work in these settings, nor to ensure delivery of coordinated, high-quality care across the network.
Creating The Children's Hospital and Child Health Network
The Bronx has a young population, with nearly one-third of its residents under age 20—more than 400,000 young people. Montefiore's studies7 have shown that this population has health status indicators and hospitalization rates far worse than those of children elsewhere in New York City and the state. Bronx children suffer from a lack of access to primary care and from a high incidence and poor management of chronic diseases like asthma and diabetes. The primary care network described above was an important step in meeting their everyday medical needs, but a lack of access to specialty care continued to compromise the network's effectiveness. In the early 1990s, Montefiore began planning for an ambitious undertaking, which would put those needed specialty resources in place and connect them to Montefiore's community-based services to create a single, integrated system of pediatric care.
Ten years of planning and fund raising culminated in the fall of 2001 in the opening of a brand-new children's hospital—the first ever in the Bronx. The Children's Hospital at Montefiore is a $150 million facility with 106 beds configured in age-appropriate units, a full-service day hospital, and a complete range of ambulatory specialty services, including centers for the treatment of asthma, diabetes, kidney disease, epilepsy, sleep problems, and communications disorders, and what has become the highest-volume pediatric emergency department (50,000 visits a year) in New York City.
The Children's Hospital is the hub of Montefiore's Child Health Network. In addition to primary care, this network offers an extraordinary range of specialized programs aimed at helping the most vulnerable children, including services for children with developmental disabilities; a lead poisoning prevention and treatment program, with a lead-free Safe House, which provides temporary living quarters, health education and support services to families while their children are treated and lead-based paint is removed from their homes; and a child protection center, which has become a national and international model for combating child abuse and neglect and is one of the very few comprehensive programs operating under hospital auspices in its own freestanding facility in the community it serves.
Responding to the Needs of Other High-Risk Populations
Montefiore Medical Group and the Children's Hospital are two examples of concerted efforts by Montefiore to organize its resources to respond to the needs of the community and the particular high-need groups within it. Other initiatives that target specific populations include:
* a comprehensive AIDS program, which provides testing and counseling, case management, inpatient specialty services, ambulatory care, mental health services, access to clinical trials, community outreach, and support services for children, adolescents, and adults;
* a tuberculosis initiative, begun in 1993, which has helped to control the resurgence of tuberculosis in New York City through intensive outreach that ensures that patients with active cases complete treatment;
* special services for the elderly, including a home health agency that makes more than 400,000 visits a year; community-based geriatric medical and mental health services, with a special focus on depression, memory loss and Alzheimer's disease; and bilingual services for a large population of Hispanic elderly; and
* a community dentistry program that does extensive outreach to provide care to HIV-infected patients and other underserved populations, using portable equipment to take services into public schools, homeless shelters, substance abuse treatment programs, and other sites.
Integrating the Network with Health Information Technology
Montefiore recognized that ensuring quality and coordinating services across its expanding network would require the use of advanced health information technology. In the early 1990s, the medical center began aggressively pursuing the goal of digitizing all patient information, so that every patient in the Montefiore system would have an electronic medical record available online whenever it was needed by any health professional involved in the patient's care at any time and at any location in the system.
Over the past decade, the medical center has invested more than $125 million in information systems. The backbone is a clinical information system (CIS) that includes computerized physician order entry (CPOE) for online ordering of prescriptions and scheduling of tests, online results reporting, expert medical systems, and decision support tools. Currently available in all inpatient areas and many of Montefiore's ambulatory sites, the CIS is in the process of being extended across the network to all sites, making Montefiore one of the very few 100% CPOE systems in the country. The system has produced dramatic improvements in quality and efficiency and a sharp reduction in medication errors.
An added benefit is that the CIS is linked to a data warehouse that allows Montefiore to store large amounts of clinical information, which can be retrieved and aggregated in useful ways to study the care provided to particular patient populations and the results achieved. Using software developed at Montefiore called “Clinical Looking Glass,” doctors can examine data aggregated by specific site by many practitioners or by as few as one practitioner and can determine, for example, how many patients with heart attacks received beta-blockers or how many diabetic patients have had their blood sugar controlled successfully, compare their performance to accepted standards and gauge where improvement is needed. For the first time, the medical center has the capacity to track the health of patient populations both in the hospital and beyond its walls and to use that information to design, manage, and evaluate focused interventions to meet their needs.
Using Care-Management Systems to Improve Quality
In 1995, Montefiore took additional steps to integrate its system. It organized its entire provider community—hospitals, all full-time physicians, and as many voluntary physicians as chose to participate—into a single integrated provider association (IPA) and created a care management organization (CMO), through which the IPA has been able to contract with every HMO offering plans in our service area. These agreements provide for the assignment of the insurance contract to the IPA of every subscriber who elects a primary care physician in the network. In exchange for a fixed percentage of the premium, the IPA accepts the risk and the responsibility for providing all of the care, including paying for services provided by out-of-network providers.
By accepting risk, Montefiore is able to retain the cost savings generated by effective care management and invest those savings in the medical center's core missions for the benefit of the community. In this way, Montefiore has preserved the premise of managed care—that health care delivery can be improved and savings achieved by a coordinated approach and accountability for results—but kept control of the system in the hands of providers who are committed to the community.
The Montefiore IPA currently has 1,200 member physicians, including 300 primary care physicians. Under capitated payment arrangements, it is responsible for 150,000 individuals living in our community, including 22,000 Medicare beneficiaries and 45,000 covered by Medicaid.
The CMO performs a number of functions to assure that these populations receive high-quality care. For example, using proven disease-management techniques, it tracks and manages care across the Montefiore system, focusing on chronic illnesses, such as congestive heart failure, diabetes, and asthma. These disease-management programs have already increased compliance with recommended treatments and reduced hospital admissions. They hold enormous promise for further improvements, which are particularly relevant to the Bronx population of 150,000 seniors, 40% of whom are Montefiore patients. Montefiore is one of 12 organizations nationally, and the only provider-sponsored network, to be selected by the Centers for Medicare and Medicaid Services to participate in a demonstration program to evaluate the value of disease management for patients with chronic illnesses.
Montefiore's experience in managing care for its capitated enrollees has enabled the medical center to develop a new competency: the ability to provide population-based and population-focused care. With the twin capacities of the health information system and managed care infrastructure, the medical center is now positioned to monitor health status and key indicators (like glycosylated hemoglobins, blood cholesterol levels, or the appropriate use of angiotensin-converting enzyme inhibitors) for whole populations of patients over time and to track, manage, and improve both the processes and outcomes of care for all patients—fee-for-service and managed care—who use Montefiore's delivery system. This capacity represents Montefiore's next opportunity to expand and enhance its service and value to its community.
Already Montefiore is using this skill set to monitor the incidence of particular diseases, like diabetes, asthma, and congestive heart failure, and implementing focused quality-improvement programs to assess the care provided across the delivery system and the outcomes of that care; and the medical center is implementing programs to ensure that providers across the delivery system are employing proven best practices in caring for patients with those conditions. The potential of this set of skills and behaviors to improve the health of Montefiore's community is enormous.
Reinforcing Ethical Allocation of Resources
Inherent in any health care system are tensions around the allocation of finite resources to meet seemingly unlimited needs. In the current environment, the economic pressures on health care organizations—especially AMCs—have accentuated those tensions and increasingly put them in the position of having to choose among competing priorities and constituencies and between their own institutional well-being and the best interests of their patients and of the communities they serve. How an institution weighs competing claims and makes allocation decisions is a process that typically occurs behind closed doors and to which ethical scrutiny is rarely brought in any organized way.
Montefiore is developing a more structured approach. It decided to do so at the urging of its own Division of Bioethics, a pioneer in the area of clinical bioethics, which for 20 years has been helping patients, families, doctors, and nurses grapple with difficult choices at the bedside. The bioethics staff made the case that health care organizations themselves have moral responsibility and that principled decision making at the institutional level requires a framework for analyzing choices and trade-offs comparable to that which has long guided clinical decision making.8
Montefiore began by crafting an explicit statement of the ethical principles to which the medical center is committed. The result is what may be the first code of corporate ethics developed by an American medical center.
The Montefiore Code of Ethics consists of two main parts. The first, Organizational Principles, includes principles addressing the creation of an ethical organizational environment, the pursuit of a socially responsible agenda, the promotion of responsible stewardship, and support for fair marketing and communication practices. The second set of principles, Clinical Principles, contains principles addressing the monitoring of quality of care, support of ethical clinical decision making, promotion of multidisciplinary clinical consultation, and the protection of patient privacy and confidentiality. These various code principles are grounded ethically in two foundational principles. The first states that health care organizations have a moral obligation to protect the integrity of clinical decision making and the physician–patient relationship. The second speaks to the organization's moral obligation to conduct an ethics impact audit of decisions affecting the allocation of health care services to particular patient populations.
But articulating these principles is not enough. They must be built into real-life decision making. Montefiore has begun to address that challenge by including in its strategic planning—particularly deliberations having to do with resource allocation—explicit discussion of the impact of various investments on patient care and on pressing community needs and the consequences of choosing one course of action versus another. Though Montefiore is in the very early stages of implementing its organizational ethics program, it has recognized that it is the responsibility of senior corporate administrators to take ownership of organizational ethics issues and refer them to the Bioethics Committee when they arise. Although many corporate decisions fall outside the purview of the Bioethics Committee and are more properly dealt with in other forums, the committee is uniquely qualified to address organizational issues with ethical dimensions because it contains members from both the clinical and administrative domains.
One example of this commitment to ethical behavior on the part of the organization can be seen in Montefiore's approach to population-based care management. While it is clearly in the institution's interest to effectively manage the care of its capitated populations, investing to improve their health and reduce their use of hospitals, the extension of that behavior and set of expectations to the noncapitated populations—reducing their use of specialty care and hospitals—has the potential to dampen demand for services for which the medical center would be paid under fee-for-service insurance. Despite the financial disincentives, Montefiore has chosen to take that step, providing care as if all the patients it served were in managed care plans.
In part, this step responds to the need for management coherence, that one can give only one clear message to clinicians about what behavior is expected. But it also reflects an ethical philosophy of care (a commitment to doing the right thing), coupled with a hard-nosed business assessment that eventually, quality will be recognized and rewarded in the marketplace. In the meantime, Montefiore's efforts to identify, track and manage and improve the care for all populations it serves will continue to have an intended side effect: improving the health of our community as a whole, not just the patients we serve directly.
Montefiore's efforts in this area could provide a model for others and help move the entire health care enterprise in the direction of systems with corporate ethics programs that promote principled decision making about who receives which services and protect the interests of patients and communities, especially those most vulnerable to pressures to contain costs and minimize care.
Building Teaching and Research into the Network
In their role as builders of new knowledge and trainers of young professionals, AMCs have unique capacities to improve health in urban communities.
In the 1970s, Montefiore created a residency program, based in its community health centers, to train the physicians needed to work in those centers and in similar settings across the nation. These centers continue to serve as training sites, providing community-based experience for residents in adult and pediatric primary care, for residents in obstetrics–gynecology, and for third- and fourth-year medical students. The residency program has an unparalleled record of preparing physicians for practice in the inner-city and other underserved communities: 60% of graduates continue to practice in these settings after completing their training.9,10
Montefiore provides other training experiences throughout the network—in the mobile units delivering care to the homeless, AIDS programs, geriatric practices, dentistry outreach, substance abuse treatment, and other programs. In all of these settings, medical students and residents from a range of specialties work alongside professionals who have made career commitments to caring for underserved populations and see for themselves that, with the right supports, a long-term commitment is possible and rewarding.
The community-based sites also allow Montefiore to take research beyond the laboratory and the hospital to study health problems as they occur in the community. Through ground-breaking epidemiological studies, clinical investigations, health services research, and policy analysis, Montefiore faculty have brought attention and rigor to a wide range of conditions that disproportionately affect disadvantaged populations and have developed innovative models for education, prevention, and care management in community settings. For a few examples, see the references.11–14
Preserving Community Vitality
Montefiore sees its role in the community not just as a medical institution but also as a civic leader. This view led Montefiore to create, in 1981, a community development arm called the Mosholu Preservation Corporation (MPC), named for the neighborhood immediately surrounding the medical center and dedicated to revitalizing this area, which in the early 1980s had begun to experience the housing decay and abandonment that had ravaged other areas of the Bronx.
The MPC began the decade as a buyer of last resort for the community's most deteriorated apartment buildings. By purchasing and restoring these properties, the MPC demonstrated the value of the local residential real estate and encouraged other building owners to reinvest in their properties. The MPC then moved into projects to stimulate home ownership, including the rehabilitation and cooperative conversion of an apartment building and the construction of new condominium units. By the end of the 1980s, the MPC had seen nearly every apartment building in the neighborhood renovated.
It then turned its attention to new initiatives, publishing a community newspaper, the Norwood News, that now has a readership of more than 13,000, creating the first and only Business Improvement District in New York City to be under not-for-profit auspices, developing a community school annex, restoring historical buildings, and cleaning up the physical environment by sponsoring graffiti removal and highway adoption programs.
The MPC's modus operandi in all of these efforts is to work closely with local groups to forge a common agenda that will benefit the entire community. While the MPC's activities go far beyond the traditional medical mission, they are a vital part of an overall strategy of community improvement that bears directly on the lives of Montefiore's neighbors and indirectly upon their health.
A number of lessons can be extracted from Montefiore's experience.
Explicit, Up-Front Commitment is Needed
Taking responsibility for a community's health requires an explicit, up-front commitment. The commitment needs to be formally articulated (e.g., spelled out as part of the institution's mission statement and reiterated in an organizational code of ethics).
Have a Target Population
Broad-based commitments are meaningless without a target population. The obvious population for an urban AMC is a nearby underserved community and the vulnerable groups within it.
Isolated Outposts Do Not a Delivery System Make
To put in place all of the necessary components and organize them into a well-functioning whole, most AMCs need to expand primary care capacity, recruit a critical mass of professionals trained for the needs of urban communities and support them with the systems they need to share information and manage care across the network.
Put Your Money Where Your Mouth Is
The institution needs to put its money where its mouth is. Capitalizing a community-based network, recruiting appropriate faculty and staff, initiating new services and implementing information systems will require a multimillion-dollar investment.
Seek Outside Sources of Financial Support
Shouldering responsibility for an urban community is a lot to ask of AMCs that already have trouble finding adequate resources for their traditional mission. However, philanthropic and government support is out there for institutions that are able to make a compelling case for initiatives that respond to pressing needs.
Value Human Resources
Human resources are as important as financial resources. AMCs can attract and retain faculty to work in community settings by providing the necessary structure and support: well-designed facilities, appropriate staffing, specialty backup, information systems and a linkage to colleagues and to the educational and research opportunities of the AMC.
Train Future Community Practitioners
Academic institutions have the unique capacity to renew the human resources required for community-based systems by using these systems to train the practitioners of the future. Getting medical students and residents involved in community-based care early on may kindle an interest that becomes a long-term commitment.
Nurture a Scientific Base
A commitment to improve urban health benefits from a scientific base. AMCs should use their intellectual resources to generate knowledge about the patterns of health and disease in urban populations, develop and evaluate new treatments and make them available to underserved groups.
The Process is Ongoing
Taking responsibility for a defined community is not a static arrangement. It is an ongoing process that requires continuous assessment of the population's health and the ability to recognize emerging problems and launch organized responses to changing needs.
Needs Are High, Resources Limited
The health care needs of urban communities are high, and resources are limited. Within the constraints of a fixed budget, services that are developed to benefit one group diminish an organization's capacity to support others. Trade-offs are inevitable. Tough choices are best resolved through a transparent decision-making process that openly examines the consequences of a proposed action, invites questions about who will win and who will lose, and is forthright about the reasons for choosing one course versus another.
Use Managed Care's Financial Incentives
The financial incentives of managed care can be used to support a population-based strategy for improving urban health. By developing the systems necessary to accept risk and responsibly manage care, Montefiore has been able to retain the savings it achieves and to invest those savings in initiatives designed to improve quality and outcomes for patients and for the community. Centers that assume risk for a defined population have a real interest in keeping that population healthy.
Information Technology is Essential
Information technology is essential to integrating the components of an extensive community network, managing care across the network, and improving its performance.
Montefiore has a decades-long record of mobilizing its resources as an AMC to meet the needs of a large urban population. An extraordinarily varied range of initiatives has been launched, but the steady direction has been toward an integrated system of community-based care.
Montefiore's experience may not fit all AMCs serving urban communities, but it illustrates the nature, scope, and complexity of the task of organizing an effective system. While the routes to improving urban health will vary, every AMC serving an inner-city population can, and should, take an aggressively active role.
The time is right. Insurers are looking for organized provider groups that can offer access to a comprehensive system of care and assure quality and appropriate use. AMCs have the resources and the capacity to organize those resources to meet the demand; and, if AMCs choose to deploy it, they have the additional advantage that advanced information technology can bring to integrating the delivery system, managing care, and documenting improvements that payers value and are increasingly willing to reward. For an AMC with the proper systems in place, accepting responsibility for the community is no longer just the right thing to do. It is the strategic thing to do.