Integrated Care Management Program
Chronically ill patients with multiple medical conditions often need the most help coordinating their care. The Integrated Care Management Program (iCMP) makes caring for these vulnerable patients its top priority. The goal of the program is to help patients stay healthier longer by providing the specialized care and services they need to prevent complications and avoid hospitalizations.
The iCMP program matches high-risk patients with a nurse care manager who works closely with them and their family to develop a customized health care plan to address their specific health care needs. The care managers closely monitor the patients during office appointments and after the visit when the patient is at home using phone calls and home visits. They serve as liaisons between the patient and other members of the care team. The care managers also help coordinate services such as diagnostic tests, transportation, social services, and specialist services. The program also ensures that iCMP patients who are in the emergency room continue to receive care that is tailored to their high-risk needs.
Over the past decade, more than 13,000 patients have enrolled in active care management. The program has 85 care managers, 18 social workers, 5 pharmacists, and 8 community resource specialists.In 2014, we also launched a Pediatric High Risk Program and are working closely with primary care offices to support this best practice.
In addition to improving health outcomes for patients, iCMP is a best practice for controlling costs. Since 10% of Medicare patients represent nearly 70% of Medicare spending, this is an important contribution to overall costs of care. By coordinating all of the care that some of our sickest patients require and monitoring their health we are able to avoid unnecessary, costly hospitalizations and keep patients at home, where they are happiest.
A Proven Track Record
iCMP was borne out of a highly successful federally sponsored demonstration project conducted by Massachusetts General Hospital (MGH), beginning in 2006. The MGH Care Management Program showed the value of using care managers to care for seriously ill and medically complex patients. For example, for participants in the program hospital readmissions dropped by 20% and mortality rates by 4%. Our annual net savings were 7% among enrolled patients after accounting for the management fees paid by the Centers for Medicare & Medicaid Services (CMS) to MGH. Over the first three years MGH invested more than $8 million to operate the Care Management Program but the return on investment was high. For every dollar spent the program saved $2.65 in health care costs.
Learn more about the MGH Care Management Program.
Center for Population Health Team
Our PHM Team is dedicated to realizing effective and efficient care.Meet the Team