September 18, 2019

The Faces of High-Risk Care Management

Doris*, a Newton resident since the 1950’s, is approaching her 98th birthday this October. She’s accomplished a lot over the course of her life. She helped start the first residential home for adults with cognitive disabilities in Newton, she championed the special Olympics when it was just getting off the ground over fifty years ago, and she raised two children—Carl and Andrea. In her spare time, she enjoyed painting portraits and tinkering in her basement refinishing old furniture. After her husband passed away about ten years ago, she even went on living independently in their family home. But she found herself in a difficult situation when she broke her hip and pelvis this winter.

“My life has changed since I fell,” says Doris. “Before, I did everything myself. I lived here alone, and if I wanted to go to the doctor I called a cab. I would go, and come, and I did all that myself. Now since the broken hip I can’t do anything like that.”

Supporting the patient

The Partners HealthCare high-risk care management program, called the “Integrated Care Management Program (iCMP),” helps coordinate the care of chronically ill patients with multiple medical conditions. These complex patients, and often their families, need a little extra help coordinating their health care. The objective of iCMP is to help patients stay healthier longer by providing the specialized care and services they need to prevent complications and avoid hospitalizations.

After Doris’s hospitalization, her electronic health record flagged her for a follow-up with the high-risk care management team. In addition to the post-acute care she would need following her hip surgery, Doris suffered from anxiety, insomnia, high blood pressure and cholesterol, arthritis, mobility issues, and frailty.

She was enrolled in iCMP and paired with Patty Bonsignore, a care manager at Newton-Wellesley Hospital. Her son Carl, who lives in Georgia, was grateful for the extra help. Carl is his mother’s default caretaker since his father and sister passed away. Although he visits his mother often, he can still feel the strain of trying to coordinate her care from 1,000 miles across the country.

“When I first talked to Patty I said, ‘I live in Atlanta, and my mom’s in Massachusetts, what do I do?’ And she said, ‘I’ll take care of it.’ Then she just —she took over and knew what to do and who to talk to,” says Carl.

“Patty was very helpful to him, which means she was helpful to me,” says Doris.

Carl says, “The relationship with Patty is terrific, the connectivity is great. She makes sure the home care nurse who comes to see my mom knows what the physical therapist is doing, and the physical therapist knows what doctors’ appointments she has, what specialist she went to, and what they did—it’s very well connected.”

The Big Picture

The iCMP program matches high-risk adult patients flagged in primary care or after an acute medical event (like a hospitalization) with a nurse, social worker, or community health worker to act as a care manager. Care managers work closely with patients and their families to develop a customized care plan to address their specific needs. They help patients in a variety of ways:

  • Closely monitor the patients during their office appointments, and after the visit when a patient is at home;
  • Serve as liaisons between the patient and other members of the care team;
  • Help coordinate services such as diagnostic tests, transportation, social services, and specialist services.

Bonsignore explains that working in the high-risk care management program has allowed her to develop more all-encompassing care plans for her patients.

“It’s really looking at the big picture whereas other nursing is looking at the problem of the day. We help put the global image of the patient in perspective,” she says.

A Cornerstone 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 (such as pediatric patients and ultra-high-risk populations), and consists of close to 100 care managers, roughly 40 social workers, five pharmacists, seven community health workers, and eight community resource specialists.

“We believe our interdisciplinary approach is a major driver of iCMP’s impact. We’re proud to have a community of professionals working together from all angles to support and coordinate the care of our highest risk patients,” says Amy Flaster, MD, MBA, Associate Medical Director for Care Management at Partners Population Health.

In addition to improving health outcomes for patients, iCMP is a population health management best practice for controlling costs. 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. A 2017 study in the journal Health Affairs looked at High-Risk Care Management patients in the Partners Medicare Pioneer Accountable Care Organization (ACO). They found that rates of emergency department visits were reduced by 6 percent, hospitalizations were reduced by 8 percent, and Medicare spending was reduced by 6 percent.

A Congress of Complexities

Doris is just one of many different kinds of patients that have been helped by iCMP. They are men and women across all ages, races, and incomes:

A thirty-year-old man who, after being hospitalized for pancreatitis, addressed a substance use disorder and underlying mental health concerns.

A man in his fifties got help to quit smoking and schedule appointments with pulmonary specialists to treat his COPD.

A woman in her fifties left a domestic violence situation, found stable housing, and conquered crippling anxiety & PTSD.

A retired firefighter nearing seventy got long-term care for his lung cancer covered by his work-disability benefits as well as care-taker benefits for his wife.

And many, many more. There is no one single patient who embodies the program—as a group, they are as complex as their medical records. These patients’ wide-ranging needs are all addressed by the coordination of their iCMP care managers. iCMP not only makes sure patients are taken care of medically, it addresses their social needs to make sure they are living their best lives possible.

“It is a fantastic program,” says Carl. “We were so lucky. I don’t know of any other programs like this.”


*First Name used to protect patient privacy.

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