Leaders at Partners Healthcare, an integrated delivery system and accountable care organization, developed the Integrated Care Management Program (iCMP) using data from its enterprise data warehouse (EDW) to identify high-risk patients and best focus and optimize efforts.
Partners Healthcare needed a care management program to help with patient identification, improve outcomes, and reduce costs.
Assessed patient needs and barriers to care
Monitored patients during office visits
Identified gaps in understanding and compliance
Used phone calls and home visits to monitor patients
Coordinated care, transportation, and social and specialist services
Acted as liaisons between the patient and other care team members across settings
HealthCatalyst. Care Management: A Critical Component of Effective Population Health Management.
https://downloads.healthcatalyst.com/wp-content/uploads/2016/12/Care-Management-Critical-Component-of-Effective-Population-Health-Management.pdf. Accessed August 3, 2020.