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

Our Care Management team is comprised of nurse care managers, licensed social workers, pharmacy colleagues, and clinical support staff who collaboratively work with our primary care physicians, hospital providers, and post-acute partners to coordinate care and navigate patients to appropriate supportive resources and programs across our network or within patient’s insurance payor benefits.

We focus on reducing avoidable hospital admissions, readmissions, emergency department visits, post-acute utilization and the utilization of other health care resources by providing proactive care management strategies, including patient outreach, education and navigation, provider engagement, collaborative care continuum communication, and clinical interventions to improve patient-centered health outcomes.

HOW WE SUPPORT PROVIDERS

We leverage our extensive data warehouse and electronic health record systems to identify patients who may benefit from our Care Management outreach and programs.  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.

Examples of qualifiers for our programs include:

  • Chronic disease or condition management: hypertension, diabetes, etc.
  • Frequent emergency room visits
  • History of hospitalization or rehospitalizations
  • Identified Social Determinant of Health care gaps
  • Lack of engagement in wellness and health maintenance activities
  • Hospitalization requiring transition to a skilled nursing facility

We do accept Provider referrals for patients with any of the above identified needs. To make a referral, please contact us:  BILHPNCareManagement@bilh.org

We review patient eligibility to participate in a BILHPN Care Management program or identify other potential payer-specific opportunities and resources.

To view what some of these possible opportunities are, you can review this resource guide.        Payor CM Program Directory

Point32Health Care Management Programs

HOW WE CONNECT WITH PATIENTS

The BILHPN Care Management team connects with patients in several ways.

  • Telephonic outreach
  • Patient Portal Messaging through Electronic Medical Records
  • Two-Way secure mobile phone texting
  • Collaborative care planning meetings with hospital, SNF, home and community care transition partners
  • Facilitating referrals to payer care management programs

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