Partners HealthCare and Commonwealth Care Alliance® (CCA) today announced that they will expand their advanced Integrated Care Management Program, or iCMP PLUS. The institution’s plan is to continue the program through 2018 as part of Partners HealthCare Choice, the Partners Medicaid Accountable Care Organization (ACO). The iCMP PLUS program, supported by Partners Center for Population Health, applies CCA’s direct care and care coordination model to a select group of Partners’ highest-risk Medicaid ACO patients with the most complex health care needs, and is designed to improve health outcomes, increase quality of care, reduce health care costs, and improve patient and provider satisfaction.

In the ongoing effort to improve health care while containing costs, providers have increasingly looked for innovative ways to care for patients with the highest medical, behavioral health, and social needs. These patients account for a disproportionate share of health care costs and require complex care plans that may be better served by care outside of a traditional clinical setting. Partners and CCA launched a successful pilot in 2017 and will now expand the program.

Our general iCMP program, which has been evolving for over a decade and has a proven track record of improving quality of care, addresses the needs of the sickest 5% of the population dealing with chronic health issues. iCMP PLUS focuses on patients who are remarkably complex, just .5% of patients. These patients, our most vulnerable and frail in society, require a more intensive model than a traditional high risk care management model.  Partnering with Commonwealth Care Alliance allows us to provide these additional services tailored to the needs of these patients.

Sree Chaguturu, MD Chief Population Health Officer for Partners HealthCare

“CCA has a long and successful track record of serving these populations with an innovative care model proven to improve quality and health outcomes while reducing overall costs of care. High-intensity, community-based medical supports and individualized care plans allow us to fulfill our mission of providing the best possible care,” says Christopher D. Palmieri, President and CEO of Commonwealth Care Alliance. “The extension of the iCMP PLUS program is another great sign of the effectiveness of our model, and we look forward to continuing our collaboration with Partners.”

In the initial iCMP PLUS pilot, nearly all enrolled patients had two or more chronic conditions. Many had recurring emergency department visits, had severe and persistent mental illness, were homebound, or needed palliative care services. CCA’s industry leading patient engagement methods allowed the care partners to establish meaningful relationships to coordinate targeted preventive care with the Partners’ primary care team while mitigating acute care.

Every patient in the program has a CCA care partner (a care manager), who is a nurse practitioner, nurse, or social worker, and who serves as the patient's primary care-advocate. The care partner manages the comprehensive services needed by the patient and provides critical support to primary care providers and community specialists. All care happens within interprofessional care teams that are designed, structured, and supported by Partners clinical teams to ensure sustainability, scalability, and accountability. Care partners are largely mobile and able to provide care and resources to patients in their homes, shelters, community centers, or other convenient locations. In addition to coordinating clinical care, care partners help coordinate services such as housing support, transportation and food security obtainment.

“Accountable Care Organizations are a key mechanism in the transition from fee for service to value based care,” says Jack Rowe, MD, MPH, Medical Director for the iCMP PLUS program. “This program is very in line with the ethos of that shift. We’re trying to take more ownership and better tailor the types of interventions to the patients who need them.”

Partners and CCA will continue to utilize additional CCA care delivery solutions in the extended iCMP PLUS program, including Crisis Stabilization Units that offer respite care to those in an acute behavioral health crisis; a Mobile Integrated Health program that responds to patients’ urgent care needs in their own homes; a ready resource team of on-demand interprofessional clinicians who augment care partners as needed; a Life Choices Palliative Care program that offers an alternative to hospice; and long-term services and supports (LTSS) coordination.