We partner with the BMC Health System Population Health Systems Analytics team to produce monthly, quarterly and annual metrics.
Our performance metrics pursue three objectives:
- Optimize throughput: Serve as many of the top five percent of patients as possible by engaging patients consistently through CCM graduation
- Maximize impact: Support program sustainability by maximizing impact on utilization and transitions of care
- Engage and maintain a talented and dedicated team
Not only do we present these metrics to our stakeholders, each team participates in monthly “data huddles” to assess their impact, celebrate successes, and address areas for improvement. We are constantly reviewing outcomes and impact and responding accordingly,
We track outcomes and program impact separately, including:
- Impact on inpatient utilization
- Engagement in ambulatory care
- Reduction in total cost of care
Coming Soon
We are in the midst of choosing and implementing patient reported outcome measures (PROMs) in our work. PROMs help us understand if patients’ lives are getting better in a way that matters to them.
WellSense Care Alliance Success Story
52 y/o male admitted for observation after leaving AMA for gastrointestinal hemorrhage. PMH of GI bleed, multiple chronic conditions, PTSD, bradycardia, pulmonary emboli and struggling to manage care for partner as her PCA. Enrolled in Complex Care Management July 2023.
- Strengths: Willing to learn and engage. Communicates needs and persists to get them met.
- Barriers: Strained relationship with primary care team and struggles with learning disability.
His care management team:
- Supported patient to mend relationship with PCP
- Coordinated sleep study
- Helped obtain CPAP and hearing aides
- Assisted in completing SNAP, EAEDC, RAFT, and SSI applications
- Ensured approval of additional patient services following knee replacement
- Provided medication teaching and requested VNA for medication management
- Facilitated work with attorney to secure SSI
Patient was approved for SSI in September 2024, reports buying clothing for the first time in years and being caught up on arrears. Patient continues to attend all scheduled appointments and follow ups.
CCM in the Spotlight
The CCM team participates in volunteer opportunities throughout the year, including:
- Each year CCM volunteers with Salvation Army’s Christmas Castle at the Kroc Community Center in Dorchester. This event provides qualifying families with children aged 14 and under a food gift card and gifts for each child in the household.
- We partner with Catholic Charities to provide our patients with Thanksgiving baskets including enough goods to nourish an entire family during the holidays.
- We have also volunteered at Boston Harbor’s Ronald McDonald House cooking a meal from scratch using fresh produce from BMC’s rooftop farm to share with families while their children receive medical care.
Each year CCM submits proposals for Camden Coalition’s Annual Putting Care at the Center Conference. It is the only dedicated venue for members of the complex care field to learn, network, and create a shared agenda for improving care for people with complex needs.
Past Presentations
Boston Medical Center's Clean Power Prescription (CPP) is a pilot program that enables CCM patients endorsing utility insecurity to reduce their utility bill using renewable energy. The program, made possible by the recent installation of solar panels on BMC's rooftop, will support the physical, economic, and environmental health of CCM patients and bring eligible low-income households the benefits of cleaner, less-expensive, renewable solar power.
NPR feature on one of our patients
Reach out to anna.goldman@bmc.org or shayla.parker@bmc.org to learn more.
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