Please note, this project has transitioned into Partners Population Health Management Integrated Care Management Program. The description below and video reflect the program as it was in 2011.

High-risk patients, the sickest patients who often have chronic, complex conditions, require costly, well-coordinated care.

Three Partners HealthCare hospitals are currently involved in a care management demonstration project, funded by the Centers for Medicare and Medicaid Services (CMS). This project seeks to reduce complications and improve the coordination of care for these patients, and reduce overall costs to the patient and the health system as a whole. The typical patient enrolled in the program is 76 years old, on average, has had more than three acute-care hospitalizations per year, and was taking more than 12 active medications.

Doctors Eric Weil, of Massachusetts General Hospital, Rebecca Lee, of North Shore Medical Center, and Rebecca Cunningham, of Brigham and Women's Hospital, describe the care management demonstration project currently taking place at three Partners hospitals. The project targets high risk patients and, through a team orchestrated by a primary care physician, tries to manage their care needs appropriately.