Patient Intake

Success Stories

Integrated Care Management – Improves Care and Population Health While Reducing Costs

One hundred thirty-three million Americans, 45 percent of the population, have at least one chronic disease. Chronic diseases are responsible for 7 of 10 deaths each year, killing more than 1.7 million Americans annually. Moreover, chronic disease accounts for 86 percent of our nation’s healthcare costs.
An integrated delivery system and an accountable care organization with two large academic medical centers and six community hospitals, Partners HealthCare is increasingly compensated for outcomes of care. Recognizing the need to more effectively manage its chronically ill patients, Partners implemented an integrated care management program (iCMP) to improve the outcomes of rising-risk patients and better manage treatment costs. The iCMP is a primary-care embedded, longitudinal care management program led by a nurse care manager working collaboratively with the primary care provider and care team.
The iCMP is contributing to Partners effective management of patients and financial success in at-risk contracts. In its Pilot Phase as a Medicare Demonstration Project, the program achieved the following results:

20 percent lower hospitalization rate per 1,000 patients.
13 percent lower rates of emergency department (ED) utilization.
25 percent relative difference in mortality.

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Quality Improvement in Healthcare: An ACO Palliative Care Case Study

Quality improvement in healthcare is essential for healthcare organizations as they transition to value-based care. Including palliative care in the planning and implementation of value-based care initiatives is more important than ever—especially for accountable care organizations (ACOs). This case study reviews the OSF Healthcare community-wide palliative care program and examines their key results: a) completion of 4300 advance care plans and engagement of more than 980 physician and community facilitators; b) leveraged a healthcare enterprise data warehouse (EDW) in a heterogeneous EHR environment; c) enabled data transparency at all levels through reporting and visualizations.

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