The Beth Israel Lahey Health Performance Network is proud to provide efficient, evidence-based care coordination and support for our providers and high-risk patients.

Our Care Management team is comprised of nurse care managers, licensed social workers, pharmacy colleagues, and clinical support staff who care for patients with the highest care needs throughout our communities. We focus on reducing avoidable hospital admissions, readmissions, emergency department visits, and the utilization of other health care resources by providing proactive care management strategies, including patient education, provider engagement, cross-functional communication, and clinical interventions to improve patient-centered health outcomes in a welcoming and diverse work environment.

Driven by data, focused on patients

We leverage our extensive data warehouse and electronic health record systems to identify high-risk patients and those who may benefit from additional care resources. This may include those with:

  • Behavioral health conditions
  • Food insecurity
  • Frequent emergency room visits
  • Multiple comorbidities
  • Limited mobility or transportation
  • Noncompliance
  • Prior hospitalizations
  • Poor social support or financial barriers

We are fueled by data and guided by our patient-centered approach and care practices that show cultural awareness and foster independence. By working directly with our patients, we create care plans to address their specific needs and help them reach their health care goals, including working closely with our Pharmacy team to reduce medication misuse.

Systemwide collaboration

Many care management organizations operate independently from health care facilities or are provided by health insurance companies. Our team is integrated into the Beth Israel Lahey Health medical community. This gives us greater access to shared electronic medical records and easier access to our providers, allowing for stronger, more seamless communication and more in-depth knowledge about patient needs.

To get connected with a care manager, either as a provider or a patient, please email us.