Resources

Christine Vogeli shares insights about how Partners HealthCare launched the Integrated Care Management Program (iCMP), how the program is managed, and her advice for others getting started with care for people with complex needs.
Most complex care programs use a team approach to provide multiple services to people with complex needs while also trying to control costs. While many programs invest new resources in care for patients, a well-designed team can help control costs by allowing medical providers to work to the top of their license and delegating non-medical tasks to other team members, such as community health workers or medical assistants. The goal of this play is to help you develop and cost your care model.
Once you’ve selected your population of focus, what is your process for identifying and enrolling patients who meet your criteria for inclusion in the enhanced care program? One approach is to use multiple sources of information to validate which patients are included. For example, Cambridge Health Alliance (CHA), an Accountable Care Organization (ACO) and safety-net health system in Cambridge, Mass., uses a triage tool and a bi-directional validation process to enroll patients in an enhanced care program. This process incorporates health care utilization data, primary care provider expertise...
Enhanced care models must work with primary care providers to provide seamless care to patients with complex needs. While some programs are based within primary care practices, and others are external to it, in both cases primary care providers and complex care programs must work together as one effective team. How do you engage primary care providers to understand how best to work with them? How do you help them make the right referrals to the program? The goal of this play is to help develop the necessary partnerships to support your program.
Moving from a pilot to full-scale implementation of an enhanced care program can be challenging. Some complex care programs have used scale-up grids to help them identify steps to take in each area of the implementation as they move from working with a small number of patients to a large number. The goal of this play is to help you implement your enhanced care program.
By the Playbook staff One of the challenges in identifying patients with complex needs to enroll in an enhanced care program is that past health care utilization doesn't necessarily predict future utilization. Successful programs develop and refine criteria to enroll patients for care management. At Partners HealthCare, the Integrated Care Management Program (iCMP) has used an evolving algorithm to identify patients, using claims data and information from the electronic medical record. The program also allows primary care providers to offer their insights as to which patients would most...
This resource, the Accountable Care Atlas, is intended to help health care delivery systems identify and prioritize the competencies needed under risk-based payment. Experts agree that value-based...
This resource describes a collaboration between the Cherry Health Durham Clinic (CHDC) and Mercy Health Saint Mary’s (MHSM), which treated an overlapping population of patients with complex needs...
The Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program has engaged 25 community hospitals to advance readiness for...
This resource describes the findings of the International Experts Working Group on Patients with Complex Needs. The Commonwealth Fund established this group in 2014 to outline the components of a high...
Many patients with complex needs are living with chronic conditions that can only be improved through self-management. Brief Action Planning is a self-management support technique developed by the Centre for Collaboration, Motivation & Innovation (CCMI). It guides providers to invite patients to set health goals and create specific, deadline-driven plans to change their health behavior, if they are interested in doing so. It may not be appropriate for all patients— for example, for people whose primary challenges are not health-related, or for patients who have mental illness or dementia. The...
This play is designed to help you choose your population, and it can also help you engage patients and families in person-centered co-design.