THE MEDICALLY COMPLEX PATIENT—the 80-year-old woman with congestive heart failure, diabetes and depression who has fallen three times in the past two months—will end up receiving a great deal of hospital care. But that care will often be fragmented and poorly coordinated. Health care providers struggle with how to manage such patients’ needs while controlling costs, which can be astronomical.

Proto covered a program at Massachusetts General Hospital that was aimed at improving care for complex Medicare patients (“A Healthy Investment,” 2011). Following the success of that three-year demonstration project and a three-year extension, MGH and other organizations in the Partners HealthCare System took up the reins, expanding the program to include different age groups and other health insurers.

Initial funding came in 2006, when the federal Centers for Medicare & Medicaid Services (CMS) underwrote a pilot program at MGH to test strategies for taking care of the most vulnerable and costly Medicare patients—those with multiple medical conditions or who had one severe chronic condition. Each patient was assigned a nurse care manager to assess needs, develop interventions and coordinate care. Depending on a particular patient’s situation, the care team might help arrange transportation to get the patient to doctors’ appointments, arrange to have grab bars installed in the shower or for other home modifications to prevent falls, or connect a patient with counseling for depression. The care manager also provides support during transitions—for example, when a patient is discharged from the emergency department, and for acute and post-acute rehabilitation.

The program took a gamble that more tailored, comprehensive care would help keep patients healthier and out of the hospital. And indeed, for those who participated, emergency department visits dropped 13% and hospital admissions fell by 20%. There were annual net savings of 7% in caring for those patients and a return on investment of at least $2.65 for every dollar spent. In 2009, CMS renewed the MGH demonstration project for another three years and expanded it to include patients from two other Partners facilities—Brigham and Women’s Hospital and North Shore Medical Center.

When the demonstration—and federal funding—ended in 2011, the Population Health Management team at Partners decided to continue and expand the experiment, embedding nurse care managers in all of the system’s primary care practices to help coordinate care for some 10,000 patients. (The program is now called iCMP—the Integrated Care Management Program.)

This move beyond Medicare could have broad implications for American health care, as hospitals, physicians and insurers look for ways to improve the quality of care and patient satisfaction while reducing the cost of care. The iCMP currently focuses on high-risk patients enrolled in health plans with which Partners HealthCare has shared savings arrangements. With this structure, health plans reimburse providers using a budget that is based on patients’ historical medical expenses. Any savings achieved within those budgets are then shared among providers and health plans. This model gives providers and health plans an incentive to reduce costs while maintaining quality, through a payment model that is becoming increasingly popular.

According to Eric Weil, M.D., medical director for primary care at Population Health Management at Massachusetts General Physicians Organization, using a nurse manager to coordinate care can be an effective way to keep patients healthier and out of the hospital—and that, in turn, can provide financial benefits to the hospital under the terms of risk-based contracts. And the money that’s saved can help cover the costs of running the iCMP.

Another potential benefit of using nurse care managers comes for patients with life-threatening illnesses. The care managers can talk with them about establishing goals for their care and help them take advantage of other services that Partners offers, such as palliative care. “Palliative care can both enhance the quality of care and cut costs,” Weil says. “It can prevent patients from receiving unnecessary, costly procedures and help ensure that their wishes are being met.”

Care management was recently expanded to younger patients last year, through a pediatric iCMP targeting those under 18 years of age who have complex medical needs.

Jessica Moschella, MPH, program director for Population Health Management at Partners, says a primary reason for the effectiveness of the iCMP is that it provides long-term support. “The nurse care managers don’t just assist a patient through an acute episode or transition of care,” Moschella says. “They can provide care that is coordinated and seamless for years, even through the end of life.”

Ultimately, the Population Health Management team hopes to offer all high-risk patients the opportunity to enroll in the program, regardless of their insurance plan. “Our goal from the beginning has been to offer it to all of those who could get the most benefit,” Moschella says.