By Aine Cryts

Jack Wolf, Vice President and CIO, Montefiore Medical Center

Jack Wolf, Vice President and CIO, Montefiore Medical Center

“When it comes to the health of your population as a whole, you need to focus on everyone – not just the very sick,” said Jack Wolf, vice president and CIO at Bronx, N.Y.-based Montefiore Medical Center. “You need to figure out how to keep your whole population healthy in your region.”

Technology is a key part of the medical center’s population health success. But it’s not just a technology fix, says Wolf. The medical center also serves the needs of its region by educating students about health issues and finding homes for homeless patients.

AXIS recently discussed Montefiore’s approach to population health with Wolf.

AXIS: How does your approach to population health impact how Montefiore serves its patients?

Wolf: Our president and CEO, Steven Safyer, MD, started out in his medical practice focused on population health. He worked for Montefiore after his residency and has been here for many, many years working in community service and population health. He’s also worked on health issues with prisoners on [New York City’s] Rikers Island jail for many years. He grew through his role as chief medical officer, and then to lead our hospital where he’s focused on these same issues of community service and population health.

The vision is this: We realize that provider organizations that are successful over the next few years are going to be those that operate in the risk business. We expect to be on the hook for as many as 1.5 million lives. In order to provide care in the model where we’ve been successful, we need to think about the ability of our delivery network to serve our population.

In order to provide appropriate healthcare to a population of that size, we’ve incorporated clinical care options that work for the needs of our patients. We’ve also built a community service network to help us take care of patients who fall into high-risk categories.

AXIS: What sort of community outreach has helped to keep patients healthy?

Wolf: We work with housing authorities to find homes for homeless patients, and we educate the community on healthy food options. We’ve also helped with prescription delivery services and transportation for patients. And we’ve expanded into other areas that are probably unique to us, namely around home care for patients who can’t get in to see their physicians. We’re also reaching out to the local high school with our school health program.

When it comes to the health of your population as a whole, you need to focus on everyone—not just the very sick. You need to figure out how to keep your whole population healthy in your region.

AXIS: How does technology play into Montefiore’s population health strategy?

Wolf: Technology has been a key part of our success. We integrated our EHR and our enterprise data warehouse with our call management system, which enables us to do some predictive analytics. We’ve developed an integrated autodial structure, which allows us to reach out to patients. This is outreach to patients who may have a certain issue; perhaps they’re a healthy diabetic patient and they need to have their A1C1 level checked once a quarter or once a year.

Our call center operates as a connection point for patients. Outreach is driven from our IT system, which keeps track of which patients have had visits and which patients we need to follow up on. This also plays into how we discharge patients. Say a patient shows up in the emergency room; the emergency room doctor might be hesitant to discharge that patient, but we have care management nurses in the emergency room who can assist. Care management nurses do that by ensuring the patient gets a follow-up visit with their primary care doctor or a specialist within 24 to 48 hours—and they do it right then and there in the emergency room. After the fact, we use our IT systems to ensure that patient follow up is completed.

On the orthopedic surgery side, for example, we have done a whole series of analytics to track what’s happening with patients. They may have a problem that’s not related to their hip surgery; it may have to do with their inability to get food or care. We do a lot of follow up afterward to ensure good long-term outcomes. We’ve had some very good success in reducing readmissions in orthopedics by creating templates around the patients. That depends on the type of surgery the patient has had, but we go through a template to ensure that, post-surgery, they have a walker [if necessary], they get a follow-up visit, they can get their medications, and they have access to transportation.

 

About Jack Wolf

Jack Wolf is vice president and CIO at Montefiore Medical Center, a teaching hospital for Albert Einstein College of Medicine in the Bronx, NY.

Wolf, who has more than 17 years of experience serving healthcare organizations, leads the medical center’s executive management team in developing health information technology strategies. He has a BA in accounting from William Paterson University in Wayne, N.J., and an MBA in management and finance from Rutgers University in New Brunswick, N.J.