For patients with complex medical conditions, navigating the healthcare system can be a challenging and frustrating experience. At BWH we are focused on better coordinating care for patients with complex medical conditions through our Integrated Care Management Program (iCMP).
The goal of iCMP is to help patients stay healthier longer through proactive care coordination and interdisciplinary support. The iCMP team includes registered nurse care coordinators, social workers, community resource specialists, community health workers and pharmacists, all of whom are members of the primary care team, working closely with each patient’s primary care physician. This team helps to educate patients and families about medical conditions and wellness, teach self-management skills, and ensure communication among providers, so that care is well coordinated.
In addition to the core care coordination program, we are measuring the impact of several pilot programs designed to address the specialized needs of patients with polypharmacy, mental health diagnoses and unmet social needs. We have also instituted a program to help patients and families who are dealing with serious illnesses to have meaningful conversations with their care team about their goals and wishes.
From 2010 to 2012, Brigham and Women's participated in The Care Management for High Cost Beneficiaries Demonstration Project, which tested the use of intensive care coordination services to improve quality of care and reduce costs for Medicare beneficiaries who have one or more chronic diseases and generally incur high health care costs. This demonstration showed improved outcomes for patients enrolled in the program:
Having demonstrated that this approach improves care for patients with complex medical conditions, our goal now is to extend this program to reach more patients who may benefit.
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