Montefiore has been pioneering population health management models for decades.

The CMO, inclusive of its behavioral health division University Behavioral Associates, is a leading healthcare services organization with population health management responsibilities for more than 300,000 individuals covered through health plans and government healthcare programs. Our mission is to reduce healthcare inequities and disparities in access while improving the quality of outcomes and successfully controlling medical expenses.

We work with a network of nearly 9,000 physicians, behavioral health and ancillary providers. Care is provided to covered individuals utilizing proven interventions supported by IT, which enables them to assess and manage a patient throughout the care continuum. Our involvement spans hospital care, behavioral health, rehabilitation, outpatient care, professional services, ancillary support, community-based programs, home care, remote patient monitoring and other services that may be required to maintain a member at optimum health.

On the Forefront of Innovation

Our population health management approach draws on our clinical, behavioral and community-focused expertise along with our proven care management engine to improve the quality of care and health status of our patients. We identify and develop robust care plans for members who are most likely to experience serious and preventable medical episodes while leveraging our integrated technology solutions, which allow us to track and coordinate care across the delivery system. We have developed performance management methodologies that drive continuous improvement across clinical programs, workflows and staff. To learn more about our clinically integrated programs, click here.

A Philosophy of Whole-person Healthcare

Our philosophy is rooted in a whole-person approach, incorporating medical, behavioral health, social and community-based needs. Across any care setting, our goal is always to help members achieve optimal health while also supporting families and caregivers.  

Whole Person Health

Social Determinants of Health

A core element of Montefiore's CMO programs is the focus on the social determinants of illness and healthcare costs—unstable housing, financial distress, legal problems, lack of a regular connection to a doctor and limited social support—and how they affect the cost of an individual’s care.

Unstable Housing
Unstable housing
Substance Abuse
Substabce Abuse
Mental Health
Mental Health
Financial Distress
Financial Distress

Scalable Population Health Management

The comprehensive services of the CMO were designed to provide the administrative and care management infrastructure to support Montefiore’s value-based contracts with health plans. The ability to manage a diverse portfolio of risk-based arrangements is a reflection of our scalable organizational capabilities designed to address the evolving and dynamic needs of a complex patient population. This requires bringing together employed and independent primary and community doctors.

Innovation and Thought Leadership

Our innovative population health management model has attracted consistent local, state, national and international attention from various entities, ranging from local health systems and payers to national government health authorities. Montefiore has been chosen as a key partner for a number of innovative, value-based care partnerships with both Centers for Medicare & Medicaid Services/Center for Medicare and Medicaid Innovation (CMS/CMMI) and New York State as a result of its rich history and experience.