Population Health Management (PHM) activities are organized into five key areas: primary care, specialty care, non-hospital care, patient engagement and analytics and technology infrastructure. Partners began rolling out PHM programs in 2012, and those programs, Integrated Care Management Program and Patient-Centered Medical Home, were originally focused on primary care. Over the past few years, our PHM efforts have expanded across all phases of care as seen below.
Partners HealthCare’s primary care practices are undergoing a transformation to a more advanced model of care, the patient-centered medical home, aimed at coordinating care and proactively keeping patients healthy.
The Integrated Care Management Program matches chronically ill, medically complex patients with a nurse care manager who works closely with them and their loved ones to develop a customized health care plan to address their specific health care needs.
Through a team-based collaborative care model, we deliver provide a set of resources and support services for primary care providers to help manage patients with depression.
Using a range of technology and tools, Partners providers are helping patients get the right care at the right time, improving care coordination between primary and specialty care, and managing episodes of care to improve patient outcomes.
Our programs aim to improve access to emergency room alternatives, ensure smooth transitions to non-hospital care facilities, and provide options for home health care monitoring.
We offer multimedia tools and resources to help patients engage in and manage their own care, and be more involved in decision -making when considering treatment options.
Partners provides analytic and technology infrastructure to help support all of our PHM activities across the network.