Population Health

Community Care Management

Community Care Management is a medical management program utilized to help BIDCO PCPs provide high quality, cost efficient care to their high risk BCBSMA, THP, HPHC, and Medicare ACO patients.  BIDCO  Community Nurse Care Managers work with BIDCO PCPs (assigned by pod) and work specifically with their acute and chronically ill patients who are at high risk for hospitalization and/or  readmission.


  1. Provide individualized care management to patients at high risk for hospitalization or other high cost resources and who would benefit from more intense care management.
  2. Reduce potentially avoidable readmission rates by improving the transition of care from hospital, rehab, SNF, and homecare - to home.

Specific Responsibilities:

High Risk Care Management - Community based care management of high risk and potentially high risk managed care and Medicare patients. This includes chronically ill patients with one or more health conditions including, but not limited to, congestive heart failure, coronary artery disease, COPD, and diabetes.  Frequently seen complicating factors may include behavioral health issues, substance abuse, illiteracy, language barriers, inadequate caregiver support, and low socioeconomic status. 

  • Sources of patient identification include: OPTUM IPro, physician referral, inpatient case manager referral, BIDCO Housecalls Medicine Program.
  • Letter and telephone call to patient to promote engagement and schedule initial assessment
  • Comprehensive health assessment performed during a home visit or office visit.
  • Assessment, plan of care, and ongoing notes documented in Care Manager and patient’s electronic medical record.
  • Interventions include counseling on diet, medication, self-care, lifestyle management, teaching of early warning signs of decompensation and how to access the appropriate level of care. 
  • Care coordination includes referrals to disease management programs, community resources to meet the patient’s and caregiver’s needs, and assistance in accessing them efficiently.
  • Coordinates efforts of all health care providers who work with the patient (specialists, ED, inpatients, rehab, SNF) and ensures that all providers are aware of the patient’s medical status and care plan.
  • Follows patient between all sites and providers of care, focusing most intensively on transitions through hospitals, and keeping the primary care physician informed of the patient's status
  •  Ongoing monitoring and follow up until patient has met goals and can be safely discharged.

Care Transitions – Reduce readmission rates by improving the transition of care - from hospital, rehab, SNF, and homecare -  to home.

  • PREPARE (Program to Prevent Potentially Avoidable Readmissions).  Contact patients discharged from BIDMC and other hospitals within 3 days of discharge. Identify new problems, review discharge instructions, med reconciliation, ensure follow-up care.
  • Enroll patients needing ongoing care and follow up into High Risk Care Management

3-Day SNF Waiver Program - This program allows BIDCO providers to directly admit Medicare Shared Savings Program patients to a CMS-approved skilled nursing facility (SNF), without the previous 3 day hospital stay. Benefits to waiving 3 day admission to the hospital include:

  1. Provides patient centered care and improved patient experience
  2. Better coordination of care and timely outreach for follow-up and education
  3. Timely referrals to appropriate community resources and support in the home upon discharge
  4. Reduce Medicare spending through care improvement

For referrals contact the RN Care Manager for the SNF Program, Maureen Watchmaker, RN, CCM by calling at 617-754-1054, or by emailing at mwatchma@bidmc.harvard.edu.

Housecalls Medicine Program:

Program Description – The BIDCO Housecalls Medicine Program provides in-home medical care by Nurse Practitioners (NP) to Medicare risk, Medicare Advantage, and select commercial risk plan patients who have multiple chronic conditions with associated functional, cognitive, or psychosocial complications.
Under the direction of the BIDCO Medical Director, the Housecalls Medicine Program NP works in collaboration with the PCP and an interdisciplinary team to support the program mission.  The NP leverages shared skills of diverse physician practices, community and tertiary hospitals, and other community providers to increase quality and effectively manage costs of care by:

  1. Providing medical oversight within the home for patients enrolled in the program; and
  2. Communicating clinical information to the primary care team after each patient visit, reviewing time-sensitive changes in medications and treatment plans immediately with the physician of record.

Making a Referral – Patients who are stratified as the top 1% of high risk/high cost beneficiaries are reviewed for automatic enrollment into the Housecalls Medicine Program through Care Management and PCP review.  Additionally, patients can be referred to the program using the Real Time Referral (RTR) process.  The RTR Form that can be found here.

For questions about the BIDCO Housecalls Medicine Program, please call 617-754-1082.

Other Collaborative Arrangements:

Home IV Services — Many patients require ongoing and longer term infusion therapy to treat their medical conditions. For some patients this means regular and recurrent trips to an infusion center, while for others a stay at a long-term medical facility to complete their treatment. While the institutional setting for such treatments may be medically necessary at times, many patients could achieve similar or better outcomes with a more positive patient experience and at a lower cost using a home-based infusion therapy approach.  

Home infusion therapy has been successfully undertaken to treat patients with many conditions, including:

  • Cellulitis
  • Dehydration
  • Endocarditis
  • Pneumonia
  • GI infections
  • Osteomyelitis
  • Non-healing surgical wound
  • Gammaglobulin (IG AND Subcutaneous) for immune or demyelinating disorders
  • Inotropic support for CHF
  • TPN

BIDCO has established non-exclusive preferred provider relationships with two home infusion companies, Soleo Health and Option Care. Specially qualified nurses are able to start midlines for home infusion therapy in the patient's home.

1. Soleo Health — 5 Shawmut Road, Suite 103, Canton, MA 02021

To initiate a referral for home infusion, please call the number below:
Telephone number: 781-298-3427
Fax: 339-368-7716

To schedule a meeting with a Soleo clinician who can provide in depth information around ways they can help you, please contact: Lisa Matraia, MS, RN at lmatraia@soleohealth.com.

2.   Option Care — 257 Turnpike Road, Southborough, MA 01772

To initiate a referral for home infusion, please call the number below:
Telephone number: 877-347-9050
Fax: 508- 624- 7031

Key Contact Information:
Marie King, RN, Cell: 781-927-5427
Email for key clinical contact: Scott.shepard@optioncare.com or Marie.king@optioncare.com.

Dual Eligibility Initiatives – We are partnering with Commonwealth Care Alliance to provide coordinated services to patients who qualify for both Medicaid and Medicare. For additional information please see the BIDCO Contracted Health Plans Resource Manual.