How MaineHealth Revised Its Complex Care Management Framework

Once the COVID pandemic began to ebb, the MaineHealth integrated health system did a program evaluation and then revised its complex care management framework. At the NAACOS spring meeting, Deborah McGill, associate vice president for population health management at the MaineHealth Medical Group, described some of the changes. 


MaineHealth includes a Level 1 trauma center, eight additional hospitals, pediatric care services, a behavioral health care network, as well as home health, hospice and senior care services. 

MaineHealth Medical Group unifies all MaineHealth providers at the system’s hospitals and medical centers and more than 230 specialty and primary care practices in Maine and New Hampshire. Over 1,700 physicians work together through the MaineHealth ACO.

McGill said that care management can be a significant force when it comes to value-based care contracts, if it's done well and if it's done efficiently. “We know that traditionally care management work with patients to improve clinical outcomes by working with them to help understand what is the driver of the poor outcome.”

McGill explained that MaineHealth thought it had a pretty well-designed and well-established care management program prior to the pandemic. It was based on risk algorithms, segmenting patients, with multi-disciplinary care management teams embedded in the primary care practices. She said that what happened during the pandemic was that many more patients needed help in many ways and care managers were stretched thin. Also, people with different titles in different programs felt like their efforts were overlapping somewhat. “Because we were taking all comers and we were primarily focusing on social drivers of health, our nurses were doing the same things as our community health workers, our health coaches, and our social workers, so it made them feel like they weren't working to the top of their license or certification,” McGill said, adding that they found they had strayed away from their initial eligibility requirements.

Coming out of the pandemic, the health system decided to do a comprehensive care management program evaluation, including industry best practice benchmarking.


“We learned that if we were going to be delivering complex care management, we needed to really return to the foundation of understanding our patients and then segmenting the ones that are the most complex, based on data, and segmenting them into a program that actually was designed to address some of their issues,” McGill said. “We have programs and services within MaineHealth that address primarily social drivers of health if there's no other clinical need or no avoidable utilization.”

McGill said they decided to go back to basics. “We learned that understanding our populations is really important, and designing the programs around them is equally important. When we looked at the data, we were not seeing the outcomes that we would expect to see from a traditional complex care management program when it came to improving clinical outcomes,” she said. “We didn't see a lot of avoidable service utilization reduction.”

MaineHealth came up with a seven-part complex care management framework. It starts with proactive identification of the population —leveraging MaineHealth’s data to understand who are patients that it can impact with traditional complex care management, and how to identify patients who could benefit from other valuable resources that are available. “We created a series of population health screenings,” McGill said. “When we enroll a patient into care management, those screenings help us to understand what are the drivers of the poor outcomes that our patients are facing. How can we work best with them through care management? Is it more behavioral health? Is it more social drivers? Is it more clinical? Once we understand that, we create a complex plan of care in Epic for those patients.”

Previously they had a complex care management program called “Lend a Hand,” which deals with social determinants of health and involves community health workers and social workers. It also had a transitions-of-care intervention. When discharged from a hospital, a patient would get a one-time telephone call from care transition to check in with them.

MaineHealth decided to create several different programs. They kept the Lend a Hand program, They also have a complex disease care management program where they embedded remote nurses in primary care practices. 

MaineHealth also create a new program in line with the strategic goals of the MaineHealth system, providing a better care coordination for patients with end-stage chronic kidney disease, with nurses embedded in the nephrology practices. “The idea there is to slow the progression of CKD by helping to control a lot of the other co-morbidities, coordinating care, hoping to plan more in advance for dialysis or transplants or even end of life,” she said. “We also extended our transitions-of-care program to be more of a 30-day support program.

The program evaluation also found that care management resources were not equally distributed across the medical group, so they have worked to better distribute them to more rural parts of the state. 

Technology is a huge enabler, McGill stressed. Prior to the pandemic, they had a homemade complexity score. “We didn't really call it a risk score, because it wasn’t predictive of anything, but it was a conglomeration of different data that we use,” she said. “We just gained access to the risk score in Epic in October. We've been able to target our complex patients with more precision and get them enrolled.”