New Program Increases Access to Services

As a way to improve management of non-acute services and care needed by patients after discharge for complex medical needs, a High Risk Medical Management program has been established by BWPO Medical Management and BWH Care Coordination.

Allen Kachalia, MD; Joanne Hogan, RN; Mary Moffat, RN; Karen Sax McLoughlin and Allen Smith, MD are overseeing the effort, while Alex Koffman, RN, and Caroline Melia, RN, are sharing the responsibility on the frontlines with the patients. Koffman and Melia work with primary care physicians to identify patients who require a comprehensive list of health care services in the community. Some examples are patients with multiple complex medical conditions; those who need assistance coordinating and adhering to treatment plan; or those with histories of poor access to health care services.

The goal is to improve health and reduce preventable admissions. For those complex patient cases that qualify for more comprehensive disease management, Koffman and Melia help refer eligible patients to such programs at BWH, PCHI or within health plans.