Population Health

Complex Care Management

The Complex Care Management program is a Population Health programs designed to provide community-based care management to support medically complex Medicare Advantage, Medicare MSSP and commercially insured risk patients. The goals of care management are to provide evidence –based, efficient and cost effective support and care coordination to our core customers- patients and providers, enabling us to reduce potentially avoidable utilization of health resources such as hospital admissions, readmissions and ED visits. The program is a hybrid model of centrally based NCMs in Westwood as well as practice- based NCMs in the community.

Goals

  • 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.
  • Reduce potentially avoidable readmission rates by improving the transition of care from hospital, rehab, SNF, and homecare - to home.

Roles/Responsibilities
Nurse Care Manager: assigned by BIDCO Pod

    • Identifies  patients through utilization, physician  referral and predictive modeling
    • Develops an individualized  care plan for patient/caregivers based on comprehensive   assessment done via telephone, office visit or home visit
    • Provides care management to the patient in partnership with PCP and support from behavioral health, pharmacy and social work resources.
    • Facilitates  the management of care transitions to reduce potentially avoidable readmissions
    • Evaluates for advance health care planning needs

Referrals to a Care Manager
Physicians should contact the Care Manager assigned to their pod/practice. Click here for a listing of Care Management assignments.

PatientPing
PatientPing allows real-time admission and discharge notifications to a patient’s provider(s). It also allows admission sites to identify a patient’s ACO and gain access to the patient’s care team.

BIDCO’s Preferred SNF and Preferred Home Care Networks are required to use PatientPing. For more information on PatientPing or request access, please contact Joy Grover at jgrover@bidmc.harvard.edu.

For questions related to the Complex Care Management program, please contact:
Mary Lania, RN, MSN, CCM, Manager of Complex Care Management
Phone: 617-754-1034; Email: mlania@bidmc.harvard.edu