December 12, 2019

The Evolution of High-Risk Care Management Part III: Self Reflection

grandmother and grandchildPartners 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 Care Management & Employee Health at Partners Population Health, shares her perspective on how we’re continually evolving and improving our cornerstone high-risk care management program. In the last installment, Dr. Flaster reflects on how we have leveraged data to improve our iCMP program and looks ahead at what’s next for the program. 

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.

iCMP is one of the oldest programs within the portfolio of population health efforts at Partners, having originated from a highly successful, federally sponsored demonstration project in 2006 before the program was scaled and rolled out across the entire Partners system. In the thirteen years since that original project, we’ve had the opportunity to examine a wealth of data about our programs. We’ve looked at the role of iCMP in cost savings, and have dug deep into what our patients want and expect from their health care providers. This year, we’re committed to reflecting on how we function as a program and how we can evolve and improve.


iCMP serves 14,000 patients across the PHS network and reaches patients across all lines. Our patients are elderly, young, and middle aged; live in urban and rural environments; speak almost 20 languages; come from all racial and ethnic backgrounds; and span almost all payer groups. This is part of what makes iCMP so special, and our impact so far-reaching.

In 2019, we embarked on a process of analyzing our program’s operations, to ensure that all patients are receiving the same care within the program, despite differences in age and demographics. Our analysis revealed that there are important inequities in our program that we are committed to addressing—variation in patient outreach attempts, care plan completion, and enrollment timelines along lines of language, ethnicity, and payer group. Therefore, in 2020, we are excited to embark on a new course, including workshops for all staff on unconscious bias, a renewed commitment to multilingual materials, ongoing training and education, and a plan to continually re-evaluate the state of disparities in the program.


Given the complexity of the patients that iCMP serves, it is expected that patients will unfortunately need to use the emergency department and the hospital when their medical issues flare. With that said, iCMP is committed to keeping patients at home with their families and in their communities if at all possible. Based on this guiding principle, iCMP embarked on the process of identifying patients who use the hospital most, understanding what might be driving these high utilization rates, and analyzing what else we could do to keep these patients healthy and at home.

From this process emerged a best practice checklist for our patients that addresses out-of-the-box needs like home supports and care access, with the ultimately goal of keeping our patients healthy and at home. We have implemented this checklist program-wide for all care managers to assess opportunities to support the health of their patients. We are excited to see the impact it has on our most complicated cohorts.


This coming year we’re looking back; we’re looking ahead; and we’re looking all around us to make iCMP the best it can be. I’m excited for what’s to come in 2020—from targeting new populations, to leveraging innovative technologies, and even taking a step back and evaluating where we’ve fallen short. There’s a lot of work ahead, but I have confidence that our amazing team across the Partners network can rise for the challenge. If you missed it, I hope you’ll read Part I and Part II of this series to understand the full scope of our iCMP goals for the coming year. As a final sign off, I want to acknowledge the incredible clinicians who make this program what it is. You are the reason we can make a meaningful difference in our patients’ lives.

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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