On December 8, the Partners HealthCare Integrated Care Management Program (iCMP) had a lot to celebrate. This year’s annual iCMP All Team Gathering commemorated the program’s 5-year-anniversary by highlighting achievements of staff members and looking forward toward expansions and project goals.

While iCMP originally started as a small pilot at Massachusetts General Hospital in 2006, the program has now expanded to every Partners institution across the system. iCMP has treated and managed the care for more than 35,450 complex, high-risk adult and pediatric patients since its full program implementation in 2012, supported by the Center for Population Health.

The teams work with mostly chronically ill patients with multiple health issues. The most common conditions in the adult program include diabetes, heart failure, and depression, and are regularly complicated by social factors, including isolation and lack of family support. Often these patients have difficulty getting to appointments or filling prescriptions and they are prone to numerous visits to the emergency room. The iCMP staff helps bridge these gaps 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 as he or she meets with primary care doctors, nurses, social workers, community resource specialists, community health workers, behavioral health clinicians, pharmacists, or specialists as needed.

At the event, David Torchiana, MD, CEO of Partners HealthCare, emphasized that the work iCMP teams are doing is vital to the way health care is shifting towards ambulatory services, care for the chronically ill, and higher standards of quality for all. Eric Weil, MD, chief medical director for primary care at Partners Center for Population Health, also spoke in more detail about the maturation of iCMP, noting “the most important things that the iCMP program has done in the past five years is to touch positively upon the lives of thousands of patients, improving their health while reducing their financial costs upon the health system as a whole.”

At the conclusion of the day, attendees assembled care packages of toothbrushes, toothpaste, thick socks, instant hand-warmers, bottled water, and cereal bars for homeless teens at the Y2Y center in Harvard Square.

“With the recent increase in Medicaid patients, iCMP has been thinking more about social supports and how we can help our most vulnerable patients,” says Maryann Vienneau, program director for iCMP and Palliative Care at the Center for Population Health. “Incorporating this simple activity into our celebration just felt right and really helped us turn our attention back to the people we serve.”

Read more about the Integrated Care Management Program here.

Topics: Integrated Care, Access to Care

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