Case Studies


Partners Healthcare: Optimizing Care Management Through Risk Stratification



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.

The Challenge


Partners Healthcare needed a care management program to help with patient identification, improve outcomes, and reduce costs.

The Approach

  • iCMP analyzed data to identify and risk-stratify patients
  • Care managers were assigned a mix of 200 at-risk patients and:
    • 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


  • $2.65 saved for every $1 spent (12% gross savings)
  • 25% relative difference in mortality
  • 13% lower emergency department (ED) utilization
  • 20% lower hospitalization rates

For more information, visit Health Catalyst


HealthCatalyst. Care Management: A Critical Component of Effective Population Health Management. Accessed August 3, 2020.