Tags: coordinated care , patient safety

Five percent of patients account for half of health care spending and patients with multiple chronic conditions cost up to seven times more than those with only one[1]. Focusing on that five percent, which represents the single largest opportunity to improve care and constrain costs, can make a real difference in the lives of patients and lower costs as care is better coordinated and costly hospitalizations are avoided. At Partners HealthCare this effort is called iCMP – the Integrated Care Management Program – and it is making a difference for Partners’ patients.

iCMP program participants are chronically ill with multiple health issues. The most common conditions include diabetes, heart failure, and depression. These medical conditions are often complicated by social factors, including isolation and lack of family support.  Often these patients have difficulty getting to appointments or filling prescriptions. They are prone to numerous visits to the emergency room. 

Started at Massachusetts General Hospital (MGH) in 2006, the program now treats and manages the care for more than 13,000 complex, high risk adult and pediatric patients at every single Partners HealthCare institution. It does this by matching patients with a nurse care manager who develops custom treatment plans that address any coverage gaps. The care manager becomes the central, consistent point of contact for the patient. Other members of the care team include social workers, community resources specialists, a pharmacist, and the patient’s specialist. The iCMP team works with patients in various settings including the primary care office, at home, and in the emergency room.

Primary care physicians can only see their patients for a limited time in any given month. So iCMP’s purpose is to identify the gaps, whatever they are—from lack of resources to psychosocial problems—and ensure these barriers are overcome.

"Primary care physicians can only see their patients for a limited time in any given month,” said Eric Weil, MD, Senior Medical Director for Primary Care in Population Health Management and an MGH physician. “So iCMP’s purpose is to identify the gaps, whatever they are—from lack of resources to psychosocial problems—and ensure these barriers are overcome."

The program has a proven track record. Over the last decade, patients in the program have had 20% fewer hospital readmissions and a 4% lower mortality rate compared to similar patients who weren’t in iCMP. Over the first three years for every dollar MGH spent the program saved $2.65 in health care costs. 

Started first as a program for Medicare patients, iCMP expanded to include commercially insured patients in 2012. “With the upcoming changes to the state Medicaid program, iCMP will soon be payer blind,” Weil said. “With iCMP, we can provide comprehensive, coordinated treatment for the sickest of our patients regardless of their insurer.”

So what’s next? Weil and his colleagues are working to expand iCMP further, especially in the psychosocial space. “We want to add more social and community health workers to the team who can make resources available to support patients with behavioral health needs,” he said. This will include having social workers take the lead with some patients rather than a nurse care manager.  

“Over the past decade, Partners iCMP has become an integral part of how care is delivered by Partners clinicians,” Weil said. “Our progress is a testament to the commitment of all the organizations within Partners to continuously find ways to improve the delivery of healthcare services.”

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[1] http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/