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Massachusetts Health Policy Commission
Summer 2019
This summer edition of the Transforming Care newsletter highlights some creative communication approaches used by HPC investment awardees to engage and support their patients, such as newsletters, secure texting, 48-hour follow-up calls, and home visits. It also features some takeaways from Boston Health Care for the Homeless Program’s recent presentation to the HPC Board.

Let us know if there are particular care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. We'd love to hear from you! Email us at caredeliverytransformation@mass.gov .
Boston Health Care for the Homeless Program Leverages Coordinated Care in the Community to Support People Experiencing Homelessness
Boston Health Care for the Homeless Program (BHCHP) recently attained the highest patient engagement rate of all the MassHealth Behavioral Health Community Partners (BH CP). They accomplished this achievement by leveraging a pilot program supported by an HPC Targeted Cost Challenge Investment (TCCI).
BHCHP’s Social Determinants of Health Coordinated Care Hub (SDH Hub) for people experiencing homelessness was an HPC-funded pilot program that launched in June 2017 with the goal of reducing avoidable acute care utilization. The SDH Hub engaged over 60 of the highest cost, highest risk patients attributed to BHCHP as a participant in a MassHealth Accountable Care Organization (ACO). The pilot was expanded in June 2018 to include over 1,000 patients attributed to BHCHP through its contracts with 10 MassHealth ACOs as a BH CP.
Mary Takach, Senior Health Policy Advisor, and Kaitlyn McGary, SDH Nurse Navigator, shared key insights and results from the SDH Hub program at the July 24 HPC Board Meeting. Takach presented data from the May 2019 MassHealth Member Status and Outreach Report indicating that BHCHP’s patient engagement rate as a BH CP is over 50%, the highest of the 19 MassHealth BH CPs. “[The HPC-supported SDH Hub pilot program] enabled us to get out of the MassHealth Behavioral Health Community Partner gate fast,” Takach said.

The SDH Hub pilot featured designated case managers employed by and located at BHCHP partner organizations, as well as a care management platform which pulled data from Boston’s Homeless Management Information System and patient electronic health records to facilitate communication and data sharing across partner organizations. Takach and McGary noted how case managers facilitated a collaborative and holistic approach to patient care. For instance, while they were primarily located at the shelters and partner organizations, case managers came into BHCHP’s main practice location to discuss their patients’ care with clinical staff in person. Through this approach, the case managers “[brought] those two different cultures together… [and] open[ed] up [BHCHP staff’s] eyes to the world outside of [their] building,” Takach said.

According to BHCHP’s presentation, patients enrolled in the SDH Hub pilot showed promising outcomes, including:
  • 23 percent reduction in the average number of emergency department (ED) visits
  • 4 percent decrease in average inpatient admissions
  • Improved rates of cancer screening
  • Longer periods between inpatient care episodes
  • Increased number of housed patients

BHCHP’s SDH Hub was an 18-month-long pilot program that leveraged a $750,000 TCCI investment. To learn more about the TCCI Program, please visit our website .
HPC Investment Awardees Use Creative Communication Approaches to Better Support Patients 
Patient engagement is a critical component of many HPC investment awardee care models. Awardees in the SHIFT-Care and Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment programs have developed strategies to communicate with patients to best support their complex medical, behavioral health, and social needs. Highlighted below are examples of communication tools utilized by awardees, which take into consideration the specific needs and circumstances of their patients.
Targeted newsletters
Hebrew SeniorLife received a SHIFT-Care award to enhance the Right Care, Right Place, Right Time (R3) program, which embeds wellness teams composed of a wellness coach and wellness nurse at supportive senior housing sites to coordinate care for residents. The wellness team produces a newsletter to promote R3 to residents, explain the enhanced services it provides, and introduce key team members. The newsletter has been well received, not just by those already involved with R3 but by other residents at the housing sites. Newsletters contain brief articles on topics such as nutrition, physical health, and mental health, highlight research findings pertinent to older adults, and provide concrete tips like how to stay hydrated and how to understand insurance benefits. The R3 staff has observed an increase in engagement as residents are following up with the nurse or social worker based on what they read in the newsletter.
Secure texting
Several awardees of the CHART investment program purchased secure texting technology to enable internal communication within their multidisciplinary, hospital-based teams. In some cases, CHART teams leveraged secure texting apps to communicate with patients. Frontline staff obtained written consent to text patients directly, and used secure texting as a tool to both communicate with their patients and ensure that their patients were able to make it to their medical visits or court appointments. 
48-hour follow-up post-discharge
A key strategy used by awardees in the CHART program to reduce unnecessary hospital use was to follow up by telephone or with an in-person visit within 48 hours of discharge from the hospital. Hospitals used a variety of strategies to improve their follow-up rates, such as dedicating staff time to completing follow-up calls with patients over the weekend. For example, at MelroseWakefield and Lawrence Memorial Hospitals, community health workers (CHWs) conducted 48-hour follow-up phone calls over the weekend and answered incoming calls from recently discharged patients. Clinicians were available if there were clinical questions, or challenges that required more expertise than the CHWs could offer. At Baystate Franklin Medical Center, the team deployed mental health counselors and trained them to perform 48-hour follow-up calls with patients to avert unnecessary ED revisits on the weekends.

Over time, CHART hospitals’ performance on 48-hour follow up completion improved; the majority of hospital teams achieved a follow-up rate higher than 50%. Ultimately, 48-hour follow-ups became one of the most successfully adopted components of the program, and helped patients troubleshoot their concerns after hospital discharge. 
Lahey-Lowell Joint CHART Awardee Uses Home Visits to Support a Patient with Complex Care Needs
Many community hospitals participating in the CHART program considered home visits an integral part of their care model, representing a departure from the traditional conception of care delivery to be limited to “within the four walls” of the hospital. Meeting a patient in the home or in the community allowed CHART team members to learn more about the patient’s life circumstances that might contribute to frequent acute care use. 
A multidisciplinary care team from the Lahey-Lowell Joint CHART award used home visits to support an older adult patient who lived alone and had a history of high inpatient and ED utilization. After the patient was enrolled in the program, the CHART team reached out to the patient by phone. The patient was distraught during the phone call, prompting both the community health worker and social worker to immediately schedule a home visit.
The CHART team found the patient’s home in disarray. The patient appeared disheveled and was experiencing a racing heart, clammy skin, and urinary incontinence. The patient had injuries from prior falls in the shower and was fearful of bathing alone. The patient also expressed experiencing shame in relation to her family as a result of past drinking and a recent lapse in sobriety.
The CHART team connected the patient to a psychiatric nurse to help manage her depression and anxiety, and made arrangements for transportation to a local substance use disorder support group. The patient reached two months of sobriety but then relapsed, growing more distant from the CHART team.
The team continued to visit the patient in the home, but was unsuccessful in connecting the patient to services and realized that the patient required higher intensity care. CHART staff contacted the patient’s family and worked with them to connect the patient to intensive long term support. 
HPC Releases the CHART Program Impact Brief  
The HPC is pleased to announce the release of the CHART Program Impact Brief . Through the CHART Program, the HPC invested $70 million across 30 community hospitals between 2014 and 2018. Over the course of this investment program, community hospitals advanced their capabilities and implemented innovative care models to integrate medical, behavioral health, and social services; provide care in the community; prepare to participate in value-based care models; and leverage data and analytics to better serve their patients. The CHART Program Impact Brief provides an overview of the program and highlights community hospital achievements in reducing acute care utilization and establishing a foundation for sustainable care delivery transformation. 

Some key achievements of the CHART program include:
  • 20 awardees met or made significant improvement toward their target aims, such as reducing hospital readmissions and/or ED revisits by at least 20%.
  • ~10,000 ED fewer visits were observed at CHART hospitals than expected over the 24-month program.
  • 81% of hospitals instituted new staffing models or processes to integrate behavioral health and medical care.
  • 22 awardees worked to address CHART patients' health-related social needs.
  • 76% of CHART hospitals reported that CHART facilitated broader hospital culture changes that helped prepare them to participate in the new MassHealth Accountable Care Organization (ACO) program. 
Summer Fellows Contribute to the HPC’s Health Care Transformation and Innovation Work
Each summer, the HPC welcomes a cohort of Summer Fellows to join the staff for ten weeks. This year, the Health Care Transformation and Innovation (HCTI) team was joined by six fellows who completed projects related to the HPC’s care delivery transformation and investment priorities:
  • Joy Chen, MPH candidate at Yale School of Public Health identified factors that contributed to programmatic sustainability of the TCCI investments.
  • Allie Dawson, MPH candidate at Tufts University, made recommendations to improve the dissemination of learnings from our investment and certification programs.
  • Danielle Dean, MSW and MPH candidate at Boston University, worked on an evaluation of two TCCI programs that addressed the social determinants of health and health care spending.
  • Nia Johnson, MBE, JD, and PhD candidate at Harvard Chan School of Public Health, analyzed how investment awardees measured health-related social needs and identified barriers and best practices.
  • Deepti Kanneganti, MPP candidate at the Harvard Kennedy School of Government, conducted an environmental scan of centralized clinical quality data collection in other states and initiated research on telehealth policy opportunities.
  • Emily Leonard, MPH candidate at the Yale School of Public Health, developed recommendations on supporting behavioral health integration into primary care.
HPC board and committee meetings, and meetings and training opportunities offered by non-profit and governmental organizations focusing on health care quality improvement and cost containment.   

Health Policy Commission
Boston, MA
September 11, 2019

American College of Healthcare Executives of MA
Boston, MA
September 12, 2019

Network for Excellence in Health Innovation
Boston, MA
September 25, 2019

MA Health & Hospital Association
Framingham, MA
September 26, 2019

Commonwealth of Massachusetts
Boston, MA
October 22-23, 2019
A sampling of books, articles, podcasts that HPC staff are reading and listening to this summer. 

  • Kaiser Health News (KHN) “What the Health?”
  • Politico’s Pulse Check
  • Outcomes Rocket’s Interviews with the Most Inspiring Leaders in Health Care
  • Providers Clinical Support System (PCSS)
  • Pew Charitable Trusts “After the Fact”

  • No Visible Bruises: What We Don’t Know About Domestic Violence Can Kill Us, by Rachel Louise Snyder
  • The Radium Girls by Kate Moore
  • What Patients Say, What Doctors Hear by Danielle Ofri
Health Policy Commission
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Boston, MA 02109