asjhhumj
Please answer the following question based on the article attached…
Please answer the following question based on the article attached and paste it.
How appropriate are the organization’s disease prevention and management programs and services (such as discharge planning, home health services, vaccination services, etc.) for addressing factors that determine population health status? Be sure to provide evidence to support your claims.
Case Study
ABSTRACT: Montefiore Medical Center, an academic medical center in New York City,
has made an integrated system of care for its primarily low-income patients. This patient centered
system of hospitals, community clinics, and school-based clinics uses innovative
practices for managing chronic disease, provides access to high-quality specialty hospital
care, and employs targeted care management and robust health information technology in
support of integrated care. Although close to 80 percent of its payer mix is Medicaid
and Medicare, Montefiore has been able to achieve financial and organizational sustainability.
Factors that contribute to this success include: care management that allows for
integration across the system; building successful primary care that combines traditional
and new models; and medical systems that focus on population health and community
accountability.
OVERVIEW
The health care safety net serves a critical role in ensuring that America’s
most vulnerable populationsthose with low incomes and those without
health insurancereceive both emergency and ongoing care. According to the
Institute of Medicine (IOM), however, there is a growing disparity between
high-performing, economically successful safety-net providers and the larger
group of struggling systems.1 The IOM has also cited a need for increased federal
tracking of the changes in the health care safety net.2 To address this gap,
The Commonwealth Fund has increased its efforts to study the safety net to
identify examples of high-performing systems and to offer a broader look at
emerging strategies for delivering, financing, and managing care for vulnerable
populations.3
This case study describes how Montefiore Medical Center, a not-forprofit
academic medical center in the Bronx borough of New York City, has made
a patient-centered system of care that tailors its access, delivery, and infor-
Integrated Safety-Net Health Care System October 2010
information systems to the unique needs of the primarily low-income, vulnerable populations it serves. In recent years, the medical center has sharpened its focus on the needs of the community and the patient and redoubled its emphasis on performance improvement. At the same time, Montefiore has achieved financial stability. These achievements have been realized in a community where one of four adults is uninsured, most patients have low incomes and complex needs, and insurance coverage is predominantly through Medicaid and Medicare (which together make up more than 75 percent of system revenues). Specifically, the innovations undertaken by Montefiore:
focus on better management of chronic diseases through ambulatory and primary care strategies that extend access to multiple points in the community;
provide access to high-quality specialty and hospital care; and
make greater integration of care delivery through the application of targeted care management and robust health information technology.
It is hoped that the insights offered in this
case study will be useful to safety-net systems, academic medical centers, and other stakeholders as they struggle to deliver and finance care for vulnerable populations.
MONTEFIORE’S COMMUNITY, STRUCTURE, AND ORGANIZATION
Established in 1884 as a hospital for patients with chronic illnesses, most notably tuberculosis, Montefiore Medical Center serves 500,000 residents of the Bronx and adjacent Westchester County. The Bronx is one of the poorest urban counties in the nation, where one-quarter of the adult population is uninsured and carry the burdens of disease associated with poverty: obesity, hypertension, cardiovascular disease, asthma, hepatitis C, and HIV. More than 400,000 of the Bronx’s approximately 1.4 million residents are children, almost half of all residents identify themselves as Latino/Hispanic, and nearly 36 percent identify themselves as African American (Exhibit 1). In addition, hundreds of thousands of undocumented persons live in the borough.
Although Montefiore’s size makes innovation and integration difficult, it also gives the system the power to reach thousands of patients. The system includes four hospitals, with a total of 1,491 beds: Henry and Lucy Moses Division (620 beds); Jack D. Weiler Hospital and Albert Einstein College of Medicine (396 beds); Children’s Hospital of Montefiore (106 beds); and North Division, acquired in 2007 (369 beds). These four hospitals account for 86,500 inpatient discharges, 301,000 emergency department visits, and 7,100 births annually.
Montefiore also includes 21 community-based primary care clinics (including five federally qualified health centers) that are located throughout the borough and provide 830,000 visits annually; 17 school-based clinics that provide medical, mental health, and dental services, with a total of 65,000 annual visits to 40 schools (many schools, particularly high schools, are clustered at the same site); and a care management organization with 150,000 enrollees in capitated contracts that provide a fixed payment per enrollee. Exhibit 2 provides a map showing the location, type, and penetration of Montefiore services in the Bronx and Westchester County.
Montefiore employs 17,382 staff, including 3,070 nurses, 1,625 physicians, and 1,200 medical residents and fellows. There are an additional 1,000 voluntary (independent, community-based) physicians on staff. The health system employs the faculty of Albert Einstein College of Medicine, who practice, teach, and conduct research. The Albert Einstein College of Medicine, founded with a commitment to biomedical science, education, and social justice, has been affiliated with Montefiore since 1967. In 2009, a new 10-year affiliation agreement was signed between Montefiore and the medical school, with the goal of creating an institutional partnership that aligns teaching and research efforts.
Given the poor and elderly patient population it serves, Montefiore is heavily dependent on government coverage programs for financial stability. Medicare accounts for 39 percent of Montefiore’s patient volume, and Medicaid accounts for 40 percent. (In 2007, most safety-net hospitals relied on Medicaid funding for approximately 33 percent of their patient volume,4 according to the National Association of Public Hospitals.) Self-pay patients constitute 1 percent of inpatient care and 7 percent of ambulatory care volume. The remaining volume comes from a commercially insured population, including many
New York City employees and labor union members. The system receives no direct subsidies from federal, state, or municipal governments. Its total disproportionate share hospital paymentsfederal funds provided to preserve access to care for elderly and low-income populations by financially assisting the hospitals they useare approximately $145 million annually: $100 million from Medicare and
$45 million from Medicaid.
With such a high proportion of lower-income, medically complex, and government-insured patients, safety-net hospitals often struggle just to break even. In contrast, Montefiore has been able, despite its challenges, to achieve a positive financial position: in 2009 the system had an operating margin of 1.3 percent and a total margin of 2.5 percent. Montefiore president and CEO Steven Safyer, M.D., attributes the success to efficiencies, innovation, the depth and breadth of specialty services, and patient-centered care. Montefiore’s average inpatient length of stay has dropped from 8.7 days in 1993 to 5.4 days in 2009, compared with 7.2 days for New York State hospitals and 6.7 days for New York City hospitals.
Montefiore Medical Center’s
Mission, Vision, and Values
Mission: To heal, to teach, to discover, and to advance the health of the communities they serve
Vision: To be a premier academic medical center that transforms health and enriches lives
Values: Humanity, innovation, teamwork, diversity, and equity
Source: Montefiore Medical Center.
Montefiore Integrated Delivery System BRONX
Employing Physicians to Increase Supply in Poor Communities
Over the past 25 years, Montefiore Medical Center has employed a large number of specialist and primary care physicians in response to the challenges in the 1970s and 1980s, when many private physicians left the Bronx. Montefiore also has built relationships with many of the remaining voluntary physicians in the borough. Working with this combination of employed and voluntary physicians enabled the growth of the integrated delivery system. “We wanted to attract dedicated physicians who shared our values and met the highest standards of practice,” says Dr. Safyer. Many of these employed physicians hold academic appointments at the Albert Einstein College of Medicine.
After a significant investment in primary care by Montefiore, the Bronx now has 106 primary care physicians per 100,000 population, which, although below the New York State rate of 148 per 100,000 population,5 has risen 15 percent since 1999. Montefiore has also been growing its specialty services to meet the needs of the community. Dr. Safyer believes that physicians are attracted to Montefiore because of its academic excellence combined with the community mission; half of the employed staff completed medical school or residency training at Einstein-Montefiore and remained to practice in the Bronx. Dr. Safyer trained at Montefiore, as did the chief medical officer and the medical director. “High-performing medical schools, like Einstein, need to take responsibility for their community,” says Dr. Safyer. “Physicians who are trained here prefer to focus on what the patient needs, rather than on the insurance they have.”
Montefi fi ore Medic dic dic al Center: Integrated Care Delivery for Vulnerable Populati ti ons 5
Recruiting and retaining an adequate number of specialist physicians, particularly in medicine, surgery, obstetrics, and psychiatry, remains a challenge for the system. To address this, Dr. Safyer and Montefiore’s leadership have recently built centers of excellence for liver transplants, neuroscience, heart surgery, and children’s specialties, and they have recruited over 70 physicians for these areas.
Developing a Fully Owned Care Management Organization
In 1995, Montefiore worked with its employed and voluntary physicians to establish an integrated provider association (IPA) to align the medical center and its physicians around assumption of financial risk and improvement of care delivery. The IPA board includes hospital and physician representation, with the latter including employed, voluntary, primary care, and specialty physicians. The process of creating an IPA was made somewhat easier because many of the primary care and specialty physicians on the medical staff were salaried. Still, overall it was a hard sell, as physicians were skeptical of financial risk and managed care.
Managed care had a bad name because of the assumption that it involved managing price, not care. And specialty physicians were hesitant about the emphasis on primary care it entailed. “At first, there was suspicion. To build trust, we gave the physicians a voice in decisions,” Dr. Safyer explained. “Then the subspecialists started to realize that if we increased compensation to the primary care physicians, it would bring more patients into the system. As a result, the specialists began to look at the network and financing more holistically. Overall, we got the medical staff to engage in the finances and the strategy.”
The IPA assumes financial risk from health plans in all lines of business (Medicare, Medicaid, and commercial), typically receiving less than 90 percent of the member premium to manage the medical, financial, and administrative services for members. In 1996, Montefiore established CMO, The Care Management Company as a wholly owned subsidiary. CMO manages the risk for the IPA and the medical center. It provides care management, customer service, provider relations, and claims processing services under delegated arrangements with the health plans. Approximately 6 percent to 7 percent of the IPA premium is used to support the care management infrastructure. Currently, Montefiore has 150,000 patients enrolled in capitated contracts, and has not only achieved financial health but continues to grow its capitated business. (Specific innovations, strategies, and outcomes are discussed later in this paper.)
Building an Enhanced Electronic
Health Record
Montefiore began developing its health information technology (HIT) system in 1995. Since then, it has invested close to $200 million to make a system that extends throughout its delivery network. Montefiore’s clinical information system includes inpatient, ambulatory, laboratory, imaging, and pharmacy systems, as well as a data warehouse and patient portal.
Montefiore continues to modify its information system to improve care and patient safety in collaboration with IT specialists, physicians, nurses, and other clinicians. In 1999 the inpatient service fully implemented computerized physician order entry (CPOE). An electronic sign-out system was developed to standardize patient care handoffs among inpatient units, the emergency departments, and the ambulatory network. The system also facilitated the activation of emergency protocols for conditions such as heart attack, stroke, and hypothermia.
To make better use of clinical data, Montefiore developed a data warehouse, Clinical Looking Glass (CLG), in 2000. CLG accesses Montefiore’s data systems to enable searches of aggregated data and to provide performance reports and support for clinical research. More than 700 staff have been trained to use CLG, including all internal medicine residents. CLG permits assessment of performance by physician, department, or site of care. For example, an individual report card on diabetes care was developed for all primary care residents; the report card is used as a tool to improve care.
6 The Comm mm onwealth Fund
CHRONIC DISEASE MANAGEMENT:
FROM HOSPITAL AMBULATORY CARE
TO COMMUNITY-BASED INNOVATIONS
Leadership at Montefiore Medical Center has focused on building primary care at their hospital and clinic sites to meet the complex needs of vulnerable populations. At the same time, it has reached out to the community to better understand patients’ needs and to make solutions involving strong community partnerships, public health, and social services that reach beyond traditional medical care.
Patient-Centered Primary Care to Increase Access and Continuity
Patient-centered medical homes are intended to provide preventive and primary care for patients with acute and chronic health care needs, coordinate necessary specialty care, and follow up on recommended testing. With early evidence suggesting they have the potential to improve quality, reduce costs, and narrow disparities in patient care, The Commonwealth Fund has contributed to the development of primary care medical homes in pilot sites nationwide.6 For vulnerable populations, medical homes are intended to increase access to primary care and reduce avoidable emergency department (ED) visits.
Montefiore is working toward establishing model patient-centered medical homes at two of its primary care centersFamily Health Center and Bronx East. Though still in development, specific efforts have focused on medical, administrative, and social initiatives such as:
Family Health Center has expanded its hours to two evenings a week and one Saturday a month to better meet the needs of patients who need after-hours care. This year the center plans to extend these hours to four evenings a week and four Saturdays a month.
Many safety-net clinics operate on a drop-in basis where patients arrive unscheduled and wait their turn for care. They see the first available provider and often wait hours for care. To reduce long waits and to increase continuity of care, the Family Health Center team holds 50 to 75 same-day appointment slots open each day to accommodate patients with urgent care needs. This represents 40 percent to 50 percent of total daily visits, with the highest available on Mondays.
In 2009, only 50 percent to 65 percent of patients saw their regular primary care physician during a visit at Family Health Center. Increasing the number of patients who see the same physician consistently is another strategy for providing continuity of care. In an effort to improve performance, Bruce Soloway, M.D., vice chair, Department of Family and Social Medicine, and Jose Delgado, M.H.A., administrative director, Family Health Center, are working to restructure staff into teams and manage patients as a population. The challenge, according to Dr. Soloway, continues to be providing continuity in an academic teaching practice where most physicians are practicing part time. “We have 60 percent continuity compared to 90 percent for other practices,” he says. “We’re trying to improve this by using multidisciplinary teams instead of individual physicians in our care.”
Montefiore has used IT to facilitate access to care. Family Health Center utilizes a Web portal (MyMontefiore.com) so that patients can contact medical staff by e-mail to renew prescriptions, ask questions, and receive referrals. Approximately 10 percent of the Family Health Center’s patients are accessing this system. The ambulatory electronic health record (AEHR) is the primary vehicle for collecting patient information and having it accessible for other providers. Like the inpatient clinical information system, the AEHR can be viewed by caregivers throughout the system.
To address the nutrition challenges faced by this vulnerable population, particularly those related to obesity, staff conduct healthy cooking demonstrations in the clinic waiting room. They also employ health educators who run a reading program for children. To help address cultural competency issues in the neighborhood, the center actively
Montefi fi ore Medic dic dic al Center: Integrated Care Delivery for Vulnerable Populati ti ons 7
recruits and retains staff of Hispanic, Cambodian, and Vietnamese descent.
“A blend of high-tech and low-tech fixes is what makes us successful with our population,” says Dr. Safyer. Family Health Center is applying for Medical Home designation through the National Committee for Quality Assurance (NCQA) in 2010. In recognition of the rigorous requirements to achieve this designation, New York State has enhanced Medicaid rates for primary care practices with NCQA medical home designation. “Our goal is to try to figure out how to pay for the things we see our patients need,” says Noel Brown, M.D., director of quality initiatives for the Montefiore Medical Group. “We become social entrepreneurs.” If successful, leadership plans to replicate the strategies piloted at Family Health Center at other sites.
Improving Diabetes Care Through Collaboration
Montefiore’s Diabetes Leadership Group brought clinicians and staff from across the delivery system to improve care for diabetes, which affects 12 percent of adults in the Bronx. The initiative involved senior management, clinicians, and staff from across the system, and it included nutrition and education outreach programs provided in the community.
In 2009, Montefiore executive leadership designated diabetes outcome improvements as one of the year’s annual goals. A multispecialty leadership group was assembled with representation from critical care, ambulatory, community clinics, school clinics, discharge social workers, and care managers. The team made standards of care for glycemic control, protocols for managing blood sugar in the intensive care unit, and targets for minimizing unnecessary testing on the inpatient floor.
The diabetes initiative encompasses neighborhood- and home-based efforts focused on nutrition and education:
The CMO sends individual letters to patients it manages with an A1c level greater than 9 percent.
Outreach workers have designed education materials to communicate with the diverse needs of the population based on cultural, language and education-level needs.
The team worked with the local parks department to offer free recreation center memberships to identified diabetics.
Montefiore leadership started a weekly farmer’s market on Montefiore grounds to offer vegetables and fruit to the neighborhood and has partnered with community groups to support the presence of green markets throughout the Bronx.
Five certified diabetic educators rotate through Montefiore Medical Group sites to provide education and counseling to support patient self-management. The chronic care management program at the CMO also provides centralized support to the educators for ongoing patient support between office visits.
Results to date show statistically significant reductions in inpatient glucose levels, without an increase in rates of hypoglycemia. In the outpatient setting, rates of glycemic control across ambulatory sites exceed published benchmarks. In 2008, the proportion of NCQA commercial plan beneficiaries with poor glucose control (hemoglobin A1c level over 9%) was 28 percent and among Medicaid plans was 45 percent. At Montefiore, only 14 percent of patients had a hemoglobin A1c over 9 percent for all fee-for-service and capitated payers. In 2009, the average hemoglobin A1c level for patients with diabetes in Montefiore’s primary care network was 7.3 percent, and 51 percent had levels below 7 percent.
Improving Asthma Care in the Hospital and the Community
Phillip Ozuah, M.D., Ph.D., chairman of Pediatrics at Montefiore, has focused on improving asthma care and outcomes for children in the Bronx. He analyzed internal Montefiore data and discovered that one admission was a predictor for being in the persistent category of asthma severity, which can show a need for chronic
8 The Comm mm onwealth Fund
care. So, rather than waiting for a follow-up visit from the primary care physician, which caused delay in restarting maintenance treatment, the pediatric department changed its internal protocols to have the asthma controller drugs (not just rescue medication) given and prescribed at discharge. This intervention combined with provider education has driven down readmission rates to the Children’s Hospital at Montefiore.
Focused work on improving asthma care has been extended to the community as well. Montefiore partners with the New York City Department of Education (DOE) to provide primary care in the Bronx public schools. Both organizations believe that providing basic primary care to children regardless of ability to pay would improve health and increase the likelihood of school completion. The DOE provides the space in schools, and Montefiore provides full-time primary care services, including medical, mental, dental, and community health, in 40 elementary, middle, and high schools.
During the 2008-2009 school year, 23,402 children were seen in these clinics, with 77 percent of all students in the participating schools enrolled in the program. Funding is provided through Medicaid (Montefiore receives fee-for-service Medicaid payments regardless of whether the child is enrolled in managed care), the Children’s Health Insurance Program, private insurance, and grants from the federal Health Resources and Services Administration and the New York State and City health departments. Elementary school children with asthma who attended schools with a Montefiore clinic had a 50 percent reduction in hospitalizations and ED visits and a three-day per year improvement in attendance compared with asthmatic children in schools without a Montefiore clinic.7,8
Medical Training That Focuses on Chronic Care and Social Needs
The patient population at Montefiore has complex medical and social conditions, and staff are expected to go beyond traditional medicine to find solutions for these complicated issues. For example, Jeffrey Weiss, M.D., medical director at Montefiore, requires medicine residents to call at-risk patients at home within 72 hours after discharge from the emergency department. In this way, the residents are expected to make a personal connection and begin to understand the home environment and challenges their patients face.
Residents also are chosen in accordance with this social mission. According to Mary Duggan, M.D., director of Montefiore’s Department of Family Medicine’s residency program, applicants are ranked on a scale that includes clinical skills and their ability to use the tools of social medicine to try to affect the social determinants of health. Staff also demonstrate strong ties to the health system and the community. Nearly two-thirds of Montefiore’s employees live in the Bronx. The average retention rate for nurses is
17 years, and the nurse turnover rate in 2009 was
8.06 percent.
Extending Access into the Community
Dr. Weiss and his team have focused on improving care for the most frequent users of the emergency department. To determine what circumstances could be behind the high use rate, his team conducted a 2006 randomized study of 60 (of about 600) chronic ED users. The team surveyed patients as well as the ED physicians, nurses, and residents who had been in contact with those patients. It found that unstable housing, substance abuse, and a psychiatric diagnosis were the strongest risk factors for repetitive ED use. As a result of these findings, staff made the Navigator program to determine appropriate follow-up for frequent ED users in order to meet their additional clinical, social service, and other needs. Staff also made a system that flags these high users upon arrival and then begins making plans for discharge to a transitional housing unit (provided there are no serious medical needs).
Care for the Homeless
Individuals who are homeless or at high risk for becoming homeless often seek care in the ED. To assist these individuals in receiving care and avoiding ED visits, Montefiore provided medical services on-site in
Montefi fi ore Medic dic dic al Center: Integrated Care Delivery for Vulnerable Populati ti ons 9
the Bronx’s homeless shelters and through mobile clinics for a total of 25,000 visits last year. Starting in 2009, Montefiore, in partnership with community-based organizations, began assigning a social worker to these individuals when they came to the ED. The social worker determines what services they require and how best to meet their needs. According to Anne Meara, R.N., associate vice president of Network Care Management, this initiative grew out of the demands observed in the ED and reflects the tenacity of the mission-driven staff.
Tackling Obesity
Montefiore leadership also focused on development of public health initiatives in the community. With an estimated 40 percent of Bronx children overweight or obese, Montefiore staff, working with the public school district, started a campaign to bring low-fat milk into schools. They began with the schools where Montefiore operates clinics; the program has since been implemented citywide. Replacing whole milk with low-fat milk saved 4.6 billion calories and 422 million grams of fat in aggregate for New York City school children in 2009 compared to 2004, while overall milk consumption rose slightly.9
SPECIALTY AND HOSPITAL CARE THAT PROVIDE ACCESS TO HIGH-QUALITY SERVICES FOR LOW-INCOME POPULATIONS
Expanding Access for Hepatitis C Patients in the Bronx
The Bronx has one of the highest rates of hepatitis C in the country. Hepatitis C is the leading cause of liver failure in the United States, and the most common indicator for liver transplantation. Along with expanding community outreach programs, primary care, and specialist management services of the disease, Montefiore has developed a Tranplantation Center of Excellence to offer liver transplants to Bronx residents. Montefiore began the liver transplantation program in August 2008 and has performed 29 adult and pediatric transplants since then. Prior to 2008, 75 Bronx residents had to leave the borough for liver transplant and its associated treatments. Montefiore leadership believes it is important to allow patients to stay in the borough for this complex care because they are more likely to receive continuity of care and culturally appropriate services.
Emergency Department Innovations
Low-income, uninsured, and Medicaid patients rely more on the emergency department than do people with Medicare or private coverage.10 Use of the ED is a challenge facing any safety-net hospital, and the high ED volume at Montefiore makes this particularly challenging. The annual total volume of emergency department visits at Montefiore has grown to 301,000; the average number of ED visits for safety-net hospitals nationwide is 74,226.11 Volume at Montefiore’s ED continues to grow, with an almost 350 percent increase since 1995. The average increase for hospital visits in New York City, New York State, and the United States overall has remained at less than 50 percent increases over this time period.
Staff attribute this increase to their culture of respecting the unique needs of Montefiore’s population while pushing toward higher quality, efficiencies, and appropriate access. “We believe this is in part because of our culture of being respectful to patients,” says John Gallagher, M.D., chair of Emergency Medicine. “We see EDs losing volume at other Bronx hospitals while ours continues to grow. We think this is because of word of mouth that you will get great care here and you will be treated well.”
With over 100 patients in the Moses Division ED at any given time and 3,000 visits weekly, triage has become a priority in order to separate and appropriately treat nonurgent and emergency cases. Lower-acuity patients, approximately 30 percent of the total, are triaged into a separate area for fast tracking. Patients who are discharged from the ED are called by ED staff within 72 hours of their visit for follow-up and referral.
Specific efforts have focused on improving ED care for cardiac patients. Since 2006, Montefiore has improved its “door-to-balloon” ratewhen a
10 The Comm mm onwealth Fund
patient with a heart attack is moved within 90 minutes from the ED to the cardiac catheterization lab for an angioplasty to open the affected coronary arteryfrom 11 percent in 2006 to 88 percent-100 percent in 2009 (Exhibit 3).
Montefiore’s quality improvement team developed an intervention, applicable to all patients, that had a common starting point in the ED. The previous process required the ED physician to notify a cardiology fellow, who then notified the cardiology attending physician, with additional team memberssuch as nurses and lab techniciansnotified by other means. At the quality improvement team’s recommendation, Montefiore invested in a dedicated phone network for use in managing heart attack patients, with one phone in the ED and one carried by all cardiology catheterization team members. The phone network provides immediate access and conference capabilities, allowing for mobile and concurrent communication among team members. In addition, all team members carry dedicated pagers, which are activated when an ED physician clicks a desktop heart attack notification icon on an ED computer. Finally, the team’s nursing leadership made an all-inclusive bundled heart attack medication and equipment kit for use in preparing patients in the ED, saving valuable time in locating and dispensing specific medications.
The improvement in primary angioplasty performance has enabled reductions in acute myocardial infarction (AMI) mortality rates. In the recent public report on the federal Centers for Medicare and Medicaid Services (CMS) Hospital Compare Web site, Montefiore’s AMI mortality rates (14.0%) were significantly lower than the national average (16.6%).
On hospital clinical quality measures reported by CMS (and compiled on the Commonwealth Fund Web site WhyNotTheBest.org), Montefiore performed better than the national average on composite measures of evidence-based treatment for heart attack and heart failure during the reporting period July 2008 through June 2009. Likewise, on measures of 30-day mor
