Advanced Care Management Programs Target Smallest Population with Greatest Needs
Physical conditions are far from the only drivers of a person’s health and well being. Patients’ needs are deeply influenced by a range of medical, social, and economic circumstances. These circumstances combined with chronic illness can create significant challenges for both the patient and their families. To address these challenges, the Center for Population Health has expanded its high-risk care management program (iCMP) to care for those patients with multiple conditions spanning medical issues, social and economic challenges, and behavioral health issues. The new program, iCMP PLUS, focuses on a small population of ultra-high-risk patients with the most complex, critical needs.
“If you look at the numbers, iCMP addresses the needs of the sickest 5% of the population dealing with chronic health issues,” says Sree Chaguturu, MD, Chief Population Health Officer for Partners HealthCare. “iCMP PLUS focuses in on just .5% of patients, the most complex.”
Take Luis (“Louie” to his family), an iCMP PLUS patient with a host of medical problems. He has lung cancer, congestive heart failure, asthma, type-2 diabetes, chronic kidney disease, kidney stones, as well as a developmental delay and significant cognitive impairment that makes it hard for him to remember words, grasp complex ideas, or follow general social cues.
But Luis is by no means a shut-in. He navigates Boston public transit easily, visiting his friends all over the city. He is heavily involved with his church where he attends mass four or five times a week and volunteers for the soup kitchen and coat drives. He even attends out of state conventions with other church groups.
“He’s generally a happy guy, easy going, but he’s hard-headed when he doesn’t have to be,” says Johnny, Luis’s brother and caretaker for the past 19 years.
A few minutes later, as if on cue, Johnny reminds Luis to take his inhaler. Luis says, “Maybe” with a smile and a twinkle in his eye. “I’ve been feeling pretty good. Don’t know if I need it.”
Johnny and Luis go back and forth for a while – Johnny insists Luis take his medication and Luis flippantly brushes it off. Johnny sighs and explains that this happens a lot: Luis starts to feel better and then won’t take his medication. Or he ignores little health issues that then balloon into much bigger ones.
“It’s a domino effect,” says Johnny. “The last five years have been a rollercoaster.”
If Luis doesn’t stay proactive and tell Johnny or his doctor about his small health problems—like when his breathing is getting worse or that a sore needs attention —his issues can quickly evolve into life threatening conditions that require extended hospital stays.
“It’s a herculean effort keeping him out of the hospital,” says Matthew Lawlor, MD, Luis’s primary care physician at Brigham Health. “For the past few years he’s been hospitalized in a serial fashion about once a month.”
Luis’ hospital stays have included an emergency surgery from an untreated, necrotic infection in his thigh; a week-long stay for water retention, and a two-week stay last winter for fluid in his lungs.
“He went in before Christmas and didn’t get discharged until after New Year’s,” says Johnny.
The iCMP PLUS pilot went live on June 1, 2017, and over the past year has enrolled about 119 patients from Brigham and Women’s Hospital and Massachusetts General Hospital.
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 being quadriplegic or have multiple, severe chronic illnesses like congestive heart failure or end-stage renal disease. Social factors may include homelessness, domestic violence, or homebound patients. Behavioral health issues like depression and substance use disorders are also a prevalent health-driver in this patient population. PLUS members do not necessarily have to be dealing with all three drivers simultaneously (though some are)—some patients are just so medically complex that this program best accommodates their needs.
“The philosophy is that iCMP PLUS addresses a patient’s constellation of issues either by better connecting them with their primary care doctors, or delivering care outside of the confines of a primary care office,” says Jack Rowe, MD, Medical Director for iCMP PLUS.
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.
Depending on what the patient needs, CCA can provide a significant amount of care and support to patients outside of the traditional clinical setting, meeting patients in their homes, an easily accessible public place like a coffee shop, or other place of their choosing. Other services offered through the program include help with transportation to the patient’s primary care office and acting as an interpreter for the patient.
In Luis’ case, his CCA care manager Joan Robles, NP, makes sure he’s taking his medications, monitors his weight to make sure he’s not retaining water, charts his blood sugars, and makes adjustments to his care plan to keep him stable. Robles is able to manage Luis’s case independently without Dr. Lawlor needing to sign off on prescriptions or fill out paperwork for every order. Simultaneously, she works in conjunction with Dr. Lawlor and the rest of his physicians, keeping them in the loop and escalating serious issues.
“iCMP PLUS really served as a turning point for Luis. He’s been out of the hospital for about six months now,” says Dr. Lawlor. “I’m not available to see him on a daily basis and to be managing his issues—which is why I think we needed someone like the iCMP-PLUS care team.”
iCMP, at its core, was created to provide improved quality of care to complex patients while still achieving savings through better care utilization and coordination.
“We’re trying to take more ownership and better tailor types of interventions to people who need them,” says Dr. Rowe.