Integrated Care Partners: Managing Care More Effectively

Using data from insurance claims and other analytics, ICP helps providers identify patients with chronic illnesses and at high risk of hospitalization and has established best-practice standards of care and quality metrics to keep these patients out of the hospital and improve their quality of life. About 5 percent of the U.S. population, primarily those with chronic conditions, are responsible for 50 percent of healthcare costs.

ICP’s nationally certified community care management team, made up of more than 50 registered nurses, social workers and health coaches, collaborate closely with providers to help patients with chronic diseases, such as COPD, diabetes and heart failure, manage their illnesses more effectively. When a high-risk patient leaves a hospital, for example, a care manager reviews the discharge plans, connects the patient with his or her primary care physician for follow-up, assesses the need for community-based services, and conducts a medication review. In 2015, the ICP care management team completed more than 19,000 preventive screenings for Hartford HealthCare Medical Group patients and currently has more than 3,300 patients under active care management, including patients in private, community practices.

Managing medications also is a critical aspect of patient wellness. About one-quarter to one-third of the increase in the cost of care in 2015 was due to increases in pharmacy expenses. ICP has partnered with the University of Connecticut School of Pharmacy to enhance pharmacy management, both for patients and providers, to improve outcomes and reduce costs. When patients understand their medications and how they should take them, patient outcomes improve.

Often, patients with chronic illnesses also have behavioral health issues, such as depression, which affect the patient’s ability to manage his or her illness. ICP works very closely with the Hartford HealthCare Behavioral Health Network to place behavioral health specialists in primary care practices. The behavioral health specialist can assess a patient’s situation and work with the patient at the practice or refer the patient for other behavioral health services.

With the patient’s well-being as the focus, ICP is leading the way in our region in transforming how healthcare is delivered: assisting providers in improving the quality and coordination of care and helping patients learn to manage their own care better to enjoy healthier lives.