Making a Difference as an ICP Registered Nurse

Kristie Lopez had wanted to be a nurse since she was five years old. Always drawn to helping people, she began working for CHD a decade ago as a triage nurse, and for the past five years she has served as a clinical care manager/registered nurse for Innovative Care Partners (ICP) —which is a partnership between CHD, ServiceNet, and Gandara Center.

She asserts with confidence and enthusiasm that the past five years have been the most enjoyable in her career.

“Working with the underserved is really rewarding—keeping them healthy and keeping them out of the emergency room—that’s our goal,” she said.

The state launched ICP in 2018 for providers to deliver exceptional care coordination services, meeting enrollees’ behavioral health and medical needs with the goal of keeping the people they serve healthy, reducing avoidable hospital utilization, and reducing the overall cost of health care services. The effort is designed to integrate medical services and behavioral health services, and to help address social determinants of health, such as poverty, substandard housing, poor access to transportation, and food insecurity. ICP provides care coordination through the state’s Community Partnership program—ICP is one of 20 Community Partners in Massachusetts that work with Accountable Care Organizations to deliver services.

“We make sure that the ACOs—the doctors, therapists, specialists, and psychiatrists—are all on the same page providing collaborative care,” she said. Across the state, over the past three years the Community Partners program has shown a reduction in ER visits by 21 percent and behavioral health admissions by 30 percent. “It’s incredible to be a part of this effort,” said Lopez. “This is definitely where mental health care is heading.”

She said she works in “a very supportive work environment” that is very flexible—nurses work from home a couple of days a week. “We emphasize a work-life balance because we believe that self-care is important.” Because MassHealth recently awarded ICP Community Partners contracts for its Behavioral Health and Long Term Services and Supports populations, ICP will soon hire additional registered nurses.

Lopez can’t speak highly enough of the wraparound care ICP provides, listing as an example one MassHealth enrollee in his mid-60s who had been going to the ER two or three times a month because of high blood pressure. “Sometimes his blood pressure wasn’t that high, but he had also been diagnosed with anxiety, so there were moments when he thought he was going to have a heart attack,” she said. An ICP care coordinator met with him and his primary care physician and they came up with a plan for parameters in his blood pressure readings—helping him determine when it was necessary for him to call the doctor’s office and when to visit the ER. The care coordinator and the doctor also helped him obtain PT-1 transportation, which is MassHealth’s non-emergency van, to enable him to get to his doctor’s appointments.

She explained that when it comes to social determinants of health, lack of transportation often results in missed or delayed health care appointments and poorer health care outcomes, so this is one problem that care coordination seeks to address. “The care coordinator also set him up with a personal care attendant to help remind him of his doctor’s appointments, and also to remind him when to take his medication because he was starting to have a little memory loss,” said Lopez. In addition, the care coordinator assisted in getting the enrollee a med minder, which is a pill dispenser with an auditory prompt that reminds the user when to take medication. “Since that meeting with his PCP, he hasn’t been to the emergency room once,” she said.

In fact, twice a month Lopez’s ICP team has “MVP” meetings—an acronym for multiple-visit patients—in which they discuss the enrollees who frequently go to the hospital and how to reduce these admissions. “A few weeks ago we were talking about someone who was homeless and visiting the emergency room several times a month,” she said. “He was able to get housing, and now he hasn’t been to the ER at all. You just identify basic needs, and this can reduce hospital stays and visits—it’s fascinating to me. I really do believe in this program.”

If you or someone you know would like to make a difference the lives of people who need compassion and support, ICP will be hiring caring and nurturing registered nurses to begin work in April.