June 20, 2020

Big Wins for Our Littlest Patients During COVID-19

The Pediatric Integrated Care Management Program (iCMP) 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. To do this, the program provides thoughtful, deliberate and proactive management of care across the health care delivery system, education system and community service programs.

Pediatric iCMP matches identified pediatric patients with either a nurse, social worker or community health worker to act as a care manager based on the unique needs of the patient. These care managers work closely with patients and their families to develop a customized care plan that will address their specific needs. During the COVID-19 pandemic, however, the Pediatric iCMP program has taken on a heightened level of importance, as care managers help these vulnerable patients and their families navigate difficult and unfamiliar situations.

Despite the obstacles brought on by the pandemic, administrators of the program and care managers alike have taken on these new workloads in stride to effectively meet the evolving needs of our patients. Check out the three stories from care managers* below to learn more about how the iCMP program has helped patients in recent months:

Christina Andrade, Community Health Worker, Brockton Pediatrics

“I have been working with the mother of a 19-year-old patient for quite some time. She is a single parent to a two-year-old and 19-year-old, and she was also recently in a domestic violence situation. When she confirmed with me that she had tested positive for COVID-19, I asked her if she had enough food for the next two weeks so that she could avoid going to the grocery store, and she confirmed that she did not. She was very worried about this considering she knew that she must quarantine to avoid spreading the virus to others.

Luckily, I was able to find an agency called BAMSI and spoke with its parent information network (PIN) coordinator about her situation. Although BAMSI is NOT known for delivery groceries, they assured me that they would be able to find someone within their agency to deliver my patient’s mother food within 24 hours of me speaking with them! I am very grateful that we are able to work with agencies like BAMSI that provide such critical services to our patients at this time. When the mother called me to thank me, I was just happy that we were able to help in this situation so quickly.”

Audrey Martino, Registered Nurse, Pentucket Medical Associates

“I have had great success with COVID-19 outreach calls to my families. Every parent that I’ve talked to has expressed gratitude and appreciation for checking in on them and their children during these very stressful times. A lot of parents are stressed, worried or dealing with their own issues and don’t have anyone to talk to, so I am glad that I can be there for them. Not only am I able to provide comfort and reassurance to parents and their children, but these calls also allow me to troubleshoot problems that overwhelmed parents may be struggling with and offer the appropriate resources.

Although it’s very difficult to case manage complex patient needs remotely all the time, I find that staying organized and maintaining ‘business as usual’ by reviewing my caseload worklist in Epic every morning helps keep me on track with ongoing patient needs. These needs can include telehealth specialist appointments, school support, medication education and virtual therapies.

Another big part of my job has been reassuring parents that the office is still open and able to see patients who are ill by using technology. Technology has been indispensable not only for communicating with parents, but also with my colleagues. It has been great to see how our care management program can and does embrace all the creative, different ways that we can make our patients’ health a priority during these unprecedented times!”

Claudia Montes, Social Worker, Affiliated Pediatrics Practices

“When this pandemic hit, I feel that we were prepared and able to connect with patients right away using the technology and remote work capabilities available to us. When speaking with parents, they have all been thankful for my outreach and are eager to find out how I can help them during this pandemic. For example, many families have been having financial issues and are extremely grateful to receive the resources that we can provide related food security. This includes food banks as well as SNAP information for delivery services and/or curbside services, since some of these parents do not have anyone who is able to stay home with their children while they go food shopping. In addition, identifying mental health services with telehealth capabilities has been another major way that we can help patients and their families.

Since my team and co-workers are always connected via Skype Business and email, I don’t think the transition to remote work has affected us too much. My supervisor, director and managers are always providing updates, sharing helpful resources and checking in with us. We also have bi-weekly virtual meetings and are able to talk about our successes, as well as challenges, with patients.”


*Care managers are employed through our Population Health department to support the needs of community-based pediatric practices.

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