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Lazaro Justis has been a BWH patient for more than 20 years. The 72-year-old resident of Jamaica Plain was first referred here two decades ago when he was searching for a new physician.
Justis is among BWH’s most high-risk patients—medically complex patients who have a chronic illness or multiple combordities and need help managing their care. He suffers from back and neck pain, among other health ailments, and takes several medications. He belongs to the hospital’s integrated Care Management Program (iCMP), a key strategy of population health management at BWH—a proactive approach to patient care organized around patients’ comprehensive health needs instead of episodic interactions with providers.
Like all patients in the program, Justis has been assigned a nurse care coordinator who is part of his BWH primary care practice. These care coordinators, who are part of the Department of Care Coordination in Patient Care Services, collaborate with the primary care team to help manage every aspect of iCMP patients’ care, including working closely with community providers, specialists and all members of the care team.
“Many of these patients need an ally, especially our Spanish-speaking patients like Mr. Justis, for whom there can be many barriers, including language,” said Alina O’Connell, BSN, RN, PHN, CCM, Justis’ nurse care coordinator. “We work together with our high-risk patients to support them as they maneuver through the health care system. I loved this concept immediately when it was introduced; it really helps patients get better.”
Launched at BWH in February 2010, iCMP is an expansion of a program that began at MGH in 2006 involving high-risk Medicare patients. This population of patients accounts for a large portion of health care expenditures, and given the complexities of their health issues, they sometimes don’t see improved health. After a successful start at MGH, BWH piloted the program, achieving improved patient care outcomes through decreased hospital admissions and reduced inpatient costs as a result. By September 2011, 1,200 patients were enrolled in the program, at 12 primary care practices throughout BWH and BWFH.
In addition to a subset of Pioneer ACO patients through Medicare, the program has recently expanded to include high-risk patients with three types of commercial health insurance, for a total of 3,000 patients throughout 14 primary care practices across BWH and BWFH. The team has grown from five nurses and two social workers to 14 nurses, nine social workers, a data analyst and two community resource specialists, who help patients with everything from understanding their complex health care needs to transportation to and from their primary care practice to finding support groups. Medical Director Rebecca Cunningham, MD, Ambulatory Care Coordination Nurse Director Lisa Wichmann, MS, RN, ACM, and Senior Project Manager Jan Sawiski, jointly lead the program.
“Nurse care coordinators help to foster a strong longitudinal relationship with patients,” said Cunningham. “They are the point people who pull in other members of the collaborative care team. The program is extremely relationship-dependent.”
Added Wichmann: “This model of relationship-based care is the most meaningful type of care coordination I have experienced in all of my career. It is very exciting to be part of this program.”
Like several iCMP nurse care coordinators, O’Connell is fluent in Spanish. She lights up when she speaks of Justis, one of the 200 iCMP patients she cares for. When she first met him last July, Justis was facing many health issues, including leg pain. He was also consistently visiting the ED, instead of his primary care physician, with general concerns.
Now, instead of going to the ED, Justis regularly visits O’Connell and primary care physician Michael Fischer, MD. When he needs more urgent care, he sets up an “urgi” appointment—an urgent, same-day appointment—with the Phyllis Jen Center for Primary Care.
“We have done a lot of education together about our system,” said O’Connell. “I provide him with regular reminders about medication refills and appointments. I am so proud of the progress he has made.”
Though Justis continues to experience back and neck pain, he says that working with O’Connell has improved his health, his communication with his physician and his access to care providers, appointments and medication.
“I am very happy with the care at the Brigham,” said Justis, translated by O’Connell. “Everyone from administrative assistants to doctors to nurses have been nice and respectful to me. I know how to contact Alina when I need help and that she is here to assist me as needed.”
Joseph Frolkis, MD, PhD, vice chair of Primary Care in the Department of Medicine, calls the program an exciting and successful cooperative effort. “The addition and integration of iCMP nurse care coordinators and social workers into our 14 primary care practices have improved patients’ experience and outcomes, and facilitated our continued transition to true team-based care,” he said.
Read our related Q&A with Care Coordination's Joanne Hogan, also in this issue of BWH Bulletin.