High-Risk Care Management

High-Risk Care Management

High-Risk Care Management

A Proven Track Record

Our high-risk care management program, called the “Integrated Care Management Program (iCMP),” originated from a highly successful, federally sponsored demonstration project conducted by Massachusetts General Hospital (MGH), beginning in 2006. The MGH Care Management Program showed the value of using care managers to care for seriously ill and medically complex patients. The program was scaled by Brigham and Women’s Hospital and North Shore Medical Center before it was rolled out across the entire Partners system.

Over the past decade, more than 40,000 patients have enrolled in active care management, with around 14,000 current users (as of September 2019). Today, the program has expanded to cover more targeted populations, and consists of close to 100 care managers, roughly 20 social workers, five (5) pharmacists, seven (7) community health workers, eight (8) community resource specialists.

2017 study looking at High-Risk Care Management patients in the Partners Medicare Pioneer Accountable Care Organization (ACO) found that rates of emergency department visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent.

Data-driven Decision-Making

Our high-risk care management programs are data-driven and rely on timely and accurate data to drive clinical decision-making. The machine learning algorithm for our Adult Care Management program is unique, pulling information from the patient’s Electronic Medical Record (EMR), claims data, and other variables, to identify patients who may benefit from enhanced resources. In addition to standard process metrics and member level summaries, the program relies upon ad hoc analysis to create actionable insights that allow us to make real-time changes to our processes, workflows, and patient intervention strategies.

Adult Care Management

Integrated Care Management Program (iCMP) Chronically ill patients with multiple medical conditions often need the most help coordinating their care. The Integrated Care Management Program (iCMP) is focused on caring for our patients with the most complex care needs. The objective of the iCMP program is to help patients stay healthier longer by providing the specialized care and services they need to prevent complications and avoid hospitalizations. The iCMP program matches high-risk adult patients with a nurse, social worker, or community health worker care coordinator. A patient is matched with a specific care coordinator based on the unique need of the patient. Care coordinators work closely with patients and their families to develop a customized care plan to address their specific needs. Care coordinators closely monitoring the patients during their office appointments, and after the visit when a patient is at home. They also serve as liaisons between the patient and other members of the care team. Care coordinators also help coordinate services such as diagnostic tests, transportation, social services, and specialist services. In addition to improving health outcomes for patients, iCMP is a population health management best practice for controlling costs. Since roughly 10% of Medicare patients represent nearly 70% of Medicare spending, iCMP is an important contribution to bringing down the overall costs of care. By coordinating the care of our sickest patients and monitoring their health, patients are able to avoid unnecessary, costly hospitalizations and are able to stay at home, where they are happiest.

Pediatric Care Management

Pediatric Integrated Care Management Program (iCMP) The Pediatric Integrated Care Management Program was launched in 2013 with a mission of promoting optimal health and wellbeing in the lives of the medically and psychosocially complex pediatric patient population through thoughtful, deliberate and proactive management of care across the healthcare delivery system, education system and community service programs. Pediatric iCMP matches identified pediatric patients with a nurse, social worker, or community health worker care coordinator. A patient is matched with a specific care coordinator based on the unique need of the patient. Care coordinators work closely with patients and their families to develop a customized care plan to address their specific needs. Care coordinators closely monitoring the patients during their office appointments, and after the visit when a patient is at home. They also serve as liaisons between the patient and other members of the care team. Care coordinators also help coordinate services such as diagnostic tests, transportation, social services, and specialist services. Objectives:

  • Identify and support pediatric patients eligible for Pediatric iCMP program
  • Empower patients and families to advocate for themselves
  • Develop systems & tools to support care providers in offering excellent care management for vulnerable patients
  • Successfully transition Pediatric iCMP patients to the adult iCMP program
  • Create a transparent, inclusive process across the Partners HealthCare system to develop, implement, and continually improve key service offerings

Pediatric iCMP form the Care Coordinators Patient story: It Takes a Village – Care Teams Come Together for Complex Pediatric Patients

Ultra High-Risk Care Management

iCMP PLUS As part of the Medicaid Accountable Care Organization (ACO), Partners HealthCare has expanded its care management portfolio to include iCMP PLUS, a program that provides home-based care, care coordination and access to enhanced services. The program targets complex patients who would benefit from home and community-based care. Care teams are tailored to the patients’ unique needs. Patients in iCMP PLUS are defined by three medical drivers: social or economic problems, behavioral health conditions, and medical issues. An iCMP PLUS patient could be quadriplegic or have multiple, severe chronic illnesses like congestive heart failure or end-stage renal disease. Social factors may include homelessness, domestic violence, or challenges navigating or leaving their home. Behavioral health issues like depression and substance use disorders are also a prevalent health-driver in this patient population. iCMP PLUS members do not necessarily have to be dealing with all three drivers simultaneously; some patients are so medically complex that this program best fits their needs. To help Partners deliver home-based services and to better coordinate care, Population Health is collaborating with Commonwealth Care Alliance (CCA), a community-based non-profit healthcare organization in Boston with expertise in treating this population. iCMP PLUS aims to improve overall care quality and achieve savings through coordination of care. The program approaches patient health holistically by removing barriers to improve compliance and increase appropriate care utilization. Learn more about how we care for iCMP PLUS patients in our News section.

Community Based Resources

Community Resource Connector (CRC) The Community Resource Connector (CRC) is a secure web-based tool designed to provide patient care teams with access to local resources, programs, equipment or services available to patients within their own community and surrounding communities in Massachusetts, Rhode Island and Southern New Hampshire. Today, there are roughly 3,000 resources ranging from education, family care, financial assistance, food services, housing, legal support, transportation, health care, work and medical supplies. These resources are validated every six months to make sure users are only searching the most up to date resources. Dementia Care Coordination The Massachusetts/New Hampshire Chapter of the Alzheimer’s Association® largely supports research efforts, as well as partnerships with health care organizations through the Dementia Care Coordination (DCC) initiative to provide a closed system of referrals in order to bridge the gap between dementia care services, the patient, and the provider. Objectives:

  • Reduce hospital re-admissions
  • Improve patient and caregiver outcomes: including health metrics, cost data and utilization
  • Improve overall understanding of the disease process for both the patient and their families through care consultation and education
  • Improve patient and caregiver satisfaction

Community Health Worker Collaborative The Community Health Worker role is designed to help patients address their community resource needs, while addressing their health-related social needs. Community Health Workers support longitudinal care coordination for patients in the integrated care management program (iCMP). Community Health Worker roles can also include: Patient Navigators (such as colonoscopy navigator) and Recovery Coaches (disease specific). Objective

  • Develop and facilitate implementation of patient-centered care plans
  • Assess and address social determinants of health
  • Assist with patient navigation of the health care system

The Community Health Worker Collaborative is designed to support Community Health Workers and their supervisors across the Partners system. The focus of the Collaborative is to assist with the onboarding of Community Health Workers to the integrated care management program (iCMP) and ongoing professional development.

End Stage Renal Disease (ESRD) Care Coordination

The High-Risk Care Management Program for End Stage Renal Disease (ESRD) works to provide care coordination to high-risk patients with End Stage Renal Disease. The goal of the program is to provide team-based, specialized services, led by a nurse care manager, to help patients to avoid hospitalization. The objective of the program aims to provide collaborative and engaging care by leveraging specialized services. These services are coordinated by the care manager and include:

  • Specialty referrals;
  • Post-discharge assessment;
  • Transition-of-care initiatives;
  • Management of clinical care through IT tools.

The care manager serves as a liaison between the patient and members of their care team, providing a collaborative based approach to their care. During the initial assessment, care managers identify the most high-risk patients and address their clinical needs to develop a customized health care plan. This plan is established by coordinating with the dialysis unit and Visiting Nurses Association, identifying and monitoring dialysis treatment, forming emergency department visit avoidance plan for non-emergent issues, and patient education towards self-care and medication management. Learn more about our ESRD Care Management program on our Stories page.

Serious Illness Care Program

To learn more about our Serious Illness Care Program, visit our End-of-Life Care page.

© 2019 Partners Population Health All rights reserved.