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.
Polypharmacy Program: Patients in iCMP take an average of 17 medications. The iCMP Pharmacist and Pharmacy Technician are available to help patients understand their medications, obtain their prescriptions, and take their medications correctly.
Community Health Worker Program: Community Health Workers help patients with social and behavioral health challenges navigate the health care system and better manage their medical conditions. Early results have shown a significant decrease in emergency room visits and missed appointments for the patients connected with a Community Health Worker.
Serious Illness Care Program: Nurse care coordinators, social workers and primary care physicians at BWH have received special training to facilitate conversations with seriously ill patients and their families. The goal of this program is to improve the lives and care of all patients with serious illness by increasing meaningful conversations about their values and priorities.
Results to Date
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:
Hospitalization rate among enrolled patients was 20% lower than comparison
Emergency department visit rates were 13% lower for enrolled patients
Annual mortality was lower among enrolled patients (16% versus 20% among comparison group)
For every $1 spent, the program saved at least $2.65 in reduced medical costs
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.
10,800 patients have been reviewed by BWH primary care physicians for inclusion in iCMP
3,965 patients have been selected and have engaged in iCMP