December 10, 2019

The Evolution of High-Risk Care Management Part II: Augmenting High-Quality Care with Technology

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 part two, she explores how we’re leveraging technology to better meet patients’ needs both inside and outside the clinic. 

Amy FlasterAt 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.


Sometimes the biggest barrier to getting healthcare is getting to the office itself. Using feedback from our bi-annual patient survey, we know that more flexible access to services and transportation are at the top of our patients’ priorities. As we look to the new year, we’re excited to explore new ways to use technology to enable better care for our patients.


We think that one of the elements of iCMP that sets it apart from other care management programs is the face-to-face contact that takes place between a care manager and his or her patients. It is hard to overstate the value of a patient knowing and connecting with their care team in person. Yet, this can be hard to accomplish – whether it’s unpredictable Boston weather, transportation hindrances, or busy schedules, we know that our care managers don’t get to see their patients face-to-face as much as they’d like.

To address this, we are piloting offering virtual visits for our patients. This involves care managers like nurses, social workers, and community health workers, doing tele-visits with patients, over a computer or a smartphone. Leveraging this technology offers the promise of more frequent face-to-face contact between care managers and their patients, as well as the ability to see things like a patient’s medication bottles, any challenges in the home, and other clinical details. We are piloting this technology now, and hope that it will allow us to take our patient experience to the next level.


We know that for many iCMP patients, transportation to and from medical appointments can be a big challenge. Patients often rely on family members and friends for rides, or if a patient qualifies for state funded ride share benefits such as The Ride. Patients must complete a PT1 application and meet the state ride share eligibility requirements. To help patients address this need, we are continuing to explore ride-sharing opportunities to help support our patients.

In the past, we’ve tested the feasibility of offering ride sharing to iCMP patients, and we were happy to learn that the system works: patients and teams alike find value in the service. Now our charge is to identify ways to target patients whose care will be most impacted by ride-sharing, so that we are offering this resource to the folks who need it most.


Leveraging telehealth platforms and ride-sharing apps are just two of many new goals for iCMP in the coming year. If you missed it, read my first blog in this series about how iCMP is defining more discrete patient cohorts to meet their unique needs—specifically, those with dementia and frail elders. In my next blog, I’ll be discussing how our last goal for 2020 is to look inward and to optimize how we work as a program.

Read Part III of this series: Self Reflection 

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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