December 2, 2019

The Evolution of High-Risk Care Management Part I: Targeting Our Aging Patients

Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this three-part series, Amy Flaster, MD, MBA, Associate Medical Director for Population Health at Partners, shares her perspective on how we’re continually evolving and improving our cornerstone high-risk care management program. In the first installment, Dr. Flaster focuses on how we’re addressing the unique needs of our aging seniors. 

At Partners HealthCare, high-risk care management is the cornerstone of our population health strategy. The Integrated Care Management Program (iCMP) helps chronically ill patients with multiple medical conditions manage their care through their primary care office. While there are many iterations of iCMP that target specific populations—pediatric patients, patients with end-stage renal disease, and ultra-high-risk patients— the original program and largest cohort focuses on caring for complex adults.

The objective of the iCMP program is to help patients stay healthy by providing the specialized care and services they need to prevent complications and avoid hospitalizations. For patients who meet targeted clinical criteria, the multidisciplinary care team (primary care doctor, pharmacist, etc.) will match the patient with a nurse, social worker, or community health worker to act as their “care coordinator” (sometimes called a “care manager,” depending on the practice), who serves as a navigator for their care, and helps the patients stay at home, close care gaps, and achieve their goals of care.


As of October 2019, there are 14,200 patients enrolled in the Adult iCMP program (63 percent female, average age of 72 years). Although iCMP manages patients across all payer groups, most patients are aligned to a Partners payer risk contract under Medicare (66 percent), Medicaid (10 percent), and Commercial plans (8 percent)*.

The majority of patients are currently managed by a nurse. These patients typically have significant medical complexity. A smaller subset of patients, mostly patients with primary behavioral health issues, are managed by a social worker. An even smaller cohort of patients in the program, generally those with high health-related social needs, are managed by a community health worker.

Roughly 10 percent of Medicare patients represent more than half of Medicare spending. To address this statistic, iCMP provides targeted services to serve high-cost, high-need patients, and acts an important driver to bring 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 typically seek to be. A 2017 study in the journal Health Affairs  looked at High-Risk Care Management patients in the Partners Medicare Pioneer Accountable Care Organization (ACO) and found that the program achieved a $101 per member per month (PMPM) cost reduction.

*The remaining 16% of patients were unattributed.


As iCMP continues to mature and develop, we’re excited to continue to evolve our program. Our goal remains unchanged: to take care of the most clinically complex and vulnerable patients in the system by improving their health outcomes, making sure they get coordinated and efficient care, and keeping them out of the hospital and at home whenever possible. As we look to the new year, we’re excited to explore new ways to expand the original iCMP model to target more specific populations and their unique needs—particularly our aging population.


The Integrated Care Management Program has recently invested in a risk score technology that allows us to more consistently identify patients in our program that meet specific frailty criteria, including falls, difficulty walking, social support needs, weight loss, severe vision impairment, dementia, malnutrition, etc.

This has enabled us to think more critically about how to provide tailored care to this important and high-need cohort. With this data in hand, we have launched a frailty focus group, in collaboration with geriatricians and other subject matter experts. We are considering a number of initiatives for launch in 2020, including potential patient escorts for medical visits, resources to support caregivers carrying a significant load, designated services for frail patients, and new ways to aggregate the most helpful community resources.


In collaboration with the Partners Behavioral Health team, iCMP is excited to launch a new Memory Care Initiative that will provide additional care management, assessments, and specialized medication support for patients suffering from dementia. Many iCMP patients and their families experience the devastating impacts of dementia every day, and we are thrilled to explore new models to better support our patients and their communities on their journey.


These new patient population are just two of many new goals for iCMP in the coming year. I want to highlight even more exciting new initiatives to demonstrate how we plan to continue providing the highest level of care, while leveraging new opportunities to augment that care with technology, clinical partnerships, and new care models. Stay tuned for the next installment of this series for my thoughts on leveraging technology to better connect our high-risk patients.

Read Part II of this series – Augmenting High-Quality Care with Technology

Amy Flaster is the Associate Medical Director of Population Health Management at Partners HealthCare in Boston, where she oversees many of the clinical programs aimed at supporting ACO performance in Medicare, Medicaid and Commercial risk contracts, including care management, ED navigation, and employee health. She practices as a primary care physician at the Brigham and Women’s Hospital, and is on the faculty at Harvard Medical School.  Amy completed a medical degree from Harvard Medical School, an MBA from Harvard Business School, and trained in Internal Medicine at the Brigham and Women’s Hospital.



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