Among a small subset of patients, chronic disease comes hand-in-hand with a range of complex social and economic circumstances, creating a tangled web of critical needs and an ongoing cycle of complications and costly interventions such as extended hospitalization.

Enter the iCMP PLUS program, a year-old program out of Brigham and Women’s Hospital and Massachusetts General Hospital that builds on the population health management approach of Partners HealthCare’s existing high-risk care management program, iCMP. The new program focuses on a specific subset of ultra-high-risk patients, defined by three medical drivers: social or economic problems, behavioral health conditions, and medical issues. An iCMP PLUS patient could be quadriplegic or have multiple, severe chronic illnesses like congestive heart failure or end-stage renal disease; may be homeless or homebound; and may also cope with behavioral health issues like depression and substance use disorders.

“The philosophy is to address a patient’s constellation of issues either by better connecting them with their primary care doctors, or delivering care outside of the confines of a primary care office,” says Jack Rowe, MD, Medical Director for iCMP PLUS. Helping Partners HealthCare deliver such care is Commonwealth Care Alliance (CCA), a community-based non-profit healthcare organization in Boston with expertise in treating the complexity inherent in this population. Based on patient needs, CCA provides care and support to patients outside of the traditional clinical setting, meeting patients in their homes or accessible public locations like coffee shops. The program also offers help with transportation to the patient’s primary care office and acts as an interpreter for the patient.

With around 191 patients enrolled in the program thus far, its tailored interventions are helping to enhance care quality even while achieving higher-value spending through better utilization and coordination. “If you look at the numbers, iCMP addresses the needs of the sickest 5% of the population dealing with chronic health issues,” says Sree Chaguturu, MD, Chief Population Health Officer for Partners. “iCMP PLUS focuses in on just 0.5% of patients, the most complex.”

Read more about how iCMP PLUS has helped one Boston patient break the cycle of hospitalizations for his chronic illness here.

Topics: Integrated Care, Access to Care, Medicare/Medicaid

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