The Integrated Care Management Program (iCMP) began at Massachusetts General Hospital in 2006 to support our primary care patients with complex health issues. Our initial work was funded by the Centers for Medicare & Medicaid Case Management for High Cost Beneficiaries Demonstration Program. The iCMP is one of many programs available through the primary care practices at Mass General.
Since 2011, Mass General has supported the expansion of the program and now provides care coordination services to more than 4,000 patients annually. The iCMP team works with our patients and their providers to create a personal care plan to support the patient in achieving optimal health and well-being.
The program helps patients improve their health by identifying barriers to care, which once addressed lead to good health outcomes. Our interdisciplinary team of nurses and social workers identify our patients’ health risks, coordinate care between providers and services, and facilitate communications and transitions between hospital, rehabilitation facilities and home. For some patients this may include reviewing various treatment options or sorting through the insurance concerns.
Our patients report that iCMP alleviates the stress and confusion of navigating the health care system by putting key services in place for them, such as visiting nurses and transportation to doctor visits, preventing stress that previously would have triggered emergency department visits. Patients say that through regular telephone contact and meetings when they visit their physician’s office, the iCMP team helps to solve prescription refill problems, improves efficiency and assists with the completion of critical paperwork.
Accountable Care Organizations (ACOs) featured in Health Affairs
A recent Health Affairs article, "Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management within a Pioneer ACO," examines the impact of patient participation in a pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations, and on Medicare spending.
A Team Approach to Care
The health care system can be very complicated, particularly for patients with many health issues and related concerns. Many are receiving their care from their primary care physician and specialists, community providers and sometimes, hospital and rehabilitation facilities.
The Integrated Care Management Program (iCMP) is designed to reduce complication by supporting patients on their health care journey. Our iCMP nurses and social workers meet with patients and assess their health and social needs. Together, they identify barriers to good health and create a plan to address them. For some patients, the problems may be related to financial instability, difficulty managing personal care, or substance use. For others, it may be difficulty understanding their medical condition, social isolation or how to take their medication.
Our interdisciplinary team has the skills and experience to help patients improve their health and well-being. Our nurses teach patients about their medical issues and consider options for better health outcomes. Meanwhile, our social workers provide guidance on the social and emotional concerns related to health issues. They draw on the skills of our community resources specialists to connect patients to community services and to help them learn how to navigate the complex medical system. Similarly, our pharmacist simplifies and explains medication plans.
The iCMP team includes:
- Nurse Care Coordinator
- Social Work Care Coordinator
- Community Resource Specialist
- Community Health Worker
Below you’ll find the answers to some frequently-asked questions about the Integrated Care Management Program.
- Will I still have my doctor if I join the Integrated Care Management Program?
- Does Integrated Care Management Program cost anything?
- Where is the iCMP office located?
- Does participation in iCMP affect my insurance?
- I received a letter for the Integrated Care Management Program. Will someone call me?
- My PCP is not part of Partners Healthcare. Can I still join the program?
- Can I refer myself into the program?
The patient perspective: Utilizing focus groups to inform care coordination for high-risk Medicaid populations
Optimizing the use of electronic health records to identify high-risk psychosocial determinants of health.
Accountable care organizations at Mass General and Partners Healthcare and their goal to improve health quality and outcomes for patients.
Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management within a Pioneer ACO
Tiny daisies, Tonka trucks and assorted other buttons adorn an array of handmade, knitted sweaters donated to newborn babies at Mass General by Ruth Buchanan, who has received her care at the hospital for many years.
Pharmacy Integral to Collaborative Care at Mass General (AJHP reprint 4/1/2012)
iCMP: Focusing on the Chronically Ill to Improve Care, Reduce Costs
Mass General Integrated Care Management Program was highlighted in a 2015 Boston HubWeek video
Team players: Pharmacists critical members of Mass General’s Care Management Program
Better Care for the Most Vulnerable
Managing high-risk patients: The Mass General Care Management Program
Case Management celebrates 20 years at Mass General
Lessons for Primary Care from the First Ten years of the Medicare Coordinated Care Demonstration Projects
Revisiting Health Care’s Value Equation
Transforming Health Care: Tapping into the Innovative Capacity of Academic Medical Centers (By Peter Slavin, MD, president, Mass General)
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?
Programs for High-Need Patients: What Makes the Good Ones Good?
Increased adoption of complex care management can help meet cost savings, quality goals
Example of a Health Project: The Mass General Care Management Project
Toward Increased Adoption of Complex Care Management
Best Practices in Care Management for Senior Populations
Massachusetts General Hospital Integrated Care Management Program administrative offices:
125 Nashua Street, Suite 362
Boston, MA 02114