Evidence and Insights from Implementing an Intensive Care Management Program

Liz Gipson, Center for Health Care Strategies

Intensive care coordination can help individuals with complex needs meet their health care goals, while potentially lowering health-related expenditures. Currently, there is limited evidence from randomized controlled trials (RCTs) on the effectiveness of care coordination programs. Notably, the two largest RCTs in the field from the Camden Coalition and CareMore showed mixed results. However, a new RCT of a program in Massachusetts offers insight into the positive impact intensive care coordination can have.

Mass General Brigham (MGB) developed two intensive care coordination programs known as Integrated Care Management Program (iCMP) and iCMP PLUS, which builds off of iCMP to serve patients with complex medical and social needs. Through a partnership with Commonwealth Care Alliance (CCA) to operate the program, the iCMP PLUS model uses an interdisciplinary care team to offer home-based care and care coordination to the highest-risk patients enrolled in MGB’s Medicaid accountable care organization (ACO).

A recent randomized evaluation from researchers at MGB and CCA found promising results associated with the iCMP PLUS pilot, including savings of $23,000 per year in total medical expenditures for the high-risk patients enrolled in the program. The Playbook spoke with Alysa Veidis, RN, MSN, FNP-BC, CCA’s Vice President of Advanced Clinical Care; Jack Rowe, MD, MPH, formerly a physician at MGB who now works at agilon health; and Maryann Vienneau, Program Director, Population Health Management at MGB to learn what the organizations considered when designing this intensive care management program.

How are MGB and CCA identifying patients who are eligible for iCMP PLUS? How is this population different from those who receive iCMP?

M. Vienneau: In the original pilot, we used very intensive chart review. Now we've migrated to a machine learning algorithmic-based process that uses our claims data and electronic health record (EHR) to group patient characteristics using a predicative analytic software tool. Through the evolution of the program, we've been able to identify more patients in real-time through primary care or emergency room referrals.

The patients in the iCMP program are high utilizers but tend to participate in and engage with primary care. The patients that we identify for iCMP PLUS are in the top 0.5% of utilization and cost. Comparatively, they are less active in traditional primary care. They tend to use the emergency room as their one point of care, or they go from system to system seeking care.

J. Rowe: When we started iCMP PLUS, we were surprised by the complexity and intensity of need for this subset of Medicaid-only patients, which CCA told us was significantly more complex than their general dually eligible population. There are multiple potential drivers of this, some of which were that iCMP PLUS patients may not have been able consistently engage to get their disability paperwork filed or did not have a long enough period on disability to qualify for Medicare and become dually eligible as an under 65-year-old beneficiary.

M. Vienneau: The fragmentation, the lack of coordination, the lack of support to help them through that paperwork process was something we were surprised to see here, but it makes sense. They aren't engaging in traditional health care services.

A. Veidis: The complexity of this population is intense. Most have social and behavioral health needs, and are burdened with chronic diseases, trauma, and severe mental illness. This population struggles with navigating and gaining access to services through traditional means. That’s why it’s important that we have an interdisciplinary provider team dedicated to serving this population.

What does the care team look like for iCMP PLUS patients?

A. Veidis: We're continuously adapting to ensure that the team has the right combination of skills to support the patient needs. Every person enrolled in this program has an advanced practice clinician (APC), a registered nurse, a behavioral health clinician, and a community health worker (CHW) assigned to support them. Over time, we’ve begun including licensed practical nurses to augment the model and have them focus on supporting the patients’ other care needs, including durable medical equipment. The APC drives the care and identifies, in partnership with the patient, what is most important to them. Based on this partnered assessment, the APC determines how to flex the team. With this approach we have been able to effectively engage this population at higher rates compared to traditional care.

Substance use disorders and homelessness are two common challenges for the iCMP PLUS population. Our CHWs are our community experts. They develop strong community relationships and collaborate creatively on how to, for example, engage the patient in harm reduction strategies and gain housing stability.

How does the care team identify the best place to provide care and how has that changed over time?

A. Veidis: The decision is the patient’s. At CCA we respect what we call “the dignity of risk.” We respect patients’ wishes because that's how we build trust and mature the therapeutic relationship. That strong relationship translates into patient-led engagement and successful integration back into the health care system.

Our teams are field-based and don't shy away from seeing the patient on the side of the road, in a shelter, in a coffee shop, or wherever the patient feels safe to see us. Oftentimes, we meet them in the emergency room or in the inpatient setting if they are admitted. These situations provide opportunities to engage with the full care team and continue care coordination as the patient transitions back into the community. This type of collaboration helps prevent readmissions.

A key success factor for iCMP PLUS is the relationship between MGB and CCA. How can managed care organizations (MCOs) interested in establishing partnerships with health care systems ensure effective integration and communication?

M. Vienneau: Making the CCA team feel like they are part of MGB is critical. We worked to get the CCA team members credentialed so they could function like any other provider in the MGB system. We also had the CCA team use the same EHR as MGB so that the clinical team could communicate better, share information, and get alerted when patients are in the emergency room or admitted to our hospitals. That allows CCA providers to walk into MGB institutions as if they’re a staff member. They can round with the MGB team, meet directly with the patient, or join the patient in a primary or specialty care meeting.

As other MCOs are considering this type of partnership, they must come to the table committed to becoming one. It's not easy. We were very transparent with one another about what was or wasn’t working, and we worked together to find solutions. There must be a level of trust at the beginning because without it, we can't be transparent, and we can't move forward.

A. Veidis: We're on our fifth year of partnership and it still requires weekly meetings and a dedication to work together. The joint-operating meetings with the frontline staff and our leadership work out day-to-day clinical and operational logistics. The constant focus on organization integration has been one of the strongest components of this partnership.

What lessons have you learned related to establishing complex care management programs like iCMP PLUS?

J. Rowe: There's tremendous opportunity within value-based care to facilitate care redesign and creation of care management programs. The iCMP PLUS program was created because MGB started participating in a Medicaid ACO arrangement with the state Medicaid agency.

This program is particularly intensive and resourced to match the needs of the patients enrolled in it. The best type of care management structure for a large health system will differ from a geographically distributed affiliated outpatient network. Nuance in design and execution and evaluation is so critical. We have to keep evolving our perspective on that.

M. Vienneau: Clinically, we know this program works. But if you’re an MCO, you’re approaching this from a business lens. First, you have to understand where this patient population is geographically. This is intensive care that comes with a higher price and a bigger team. You need to know if there are enough patients in each region to support this type of program. We’ve given some thought to how we could expand this program beyond the Boston metro area to reach our entire system, but it’s not easy.