CHART: partnerships and integration enhance patient care

In October 2013, the Massachusetts Health Policy Commission (HPC), launched Phase 1 of the Community Hospital Acceleration, Revitalization & Transformation (CHART) Investment Program.

HPC dispersed $10 million to 28 community hospitals “to enhance the delivery of efficient, effective health care.” HealthAlliance Hospital in Leominster, Mass. was a recipient of grants for both Phase 1 and Phase 2, which was announced in October 2014.

According to Paul McKinnon, COO, NP, HealthAlliance received $410,000 in seed money in Phase 1 to reduce the number of patients who return frequently to the hospital and to connect them to services in the community.

“We did good work in Phase 1 and got good results,” he said. Based on performance outcomes, HealthAlliance received $3.8 million over two years in Phase 2. “From a clinical perspective, we are taking the results of Phase 1 and developing them more rigorously,” he said.

Phase 1 focused on patients with a mental health diagnosis as well as those with serious mental illness. “In Phase 2, we’ll address patients with a primary or secondary mental health diagnosis and/or substance abuse,” McKinnon said, noting the timeliness of the program, given the state’s opioid crisis.

In partnership with several community agencies, HealthAlliance does a risk assessment when the patient is discharged from the emergency room. “We will find out the patient’s needs and come up with a community plan, together with the patient,” said LaShanda Anderson-Love, CHART program manager and lead analyst. A “warm handoff,” i.e., introducing the patient directly with the organization providing services, reduces fragmentation, she added.

Anderson-Love pointed out that in Phase 1, the hospital did not have a “care coordination solution system” that allowed them to develop a care plan and collaborate with community partners. “Going into Phase 2, we rectified that,” she said. The integrated system captures data from the patient’s electronic medical record (EMR). “The navigator has the history of the client and can review the record. It documents all the information.”

McKinnon added, “The traditional EMR is not built for care coordination. This system complements the EMR. The emergency department and community care plans interface into the clinical system. It’s a way for everyone to be connected, regardless of location, since the system is web-based,” he said.

HealthAlliance is focused on reducing patient revisits to the emergency department, which now stand at 518 each month, by 15 percent and emergency room length of stay by 31 percent, according to Anderson-Love. “Our sub-goals will be collecting data to submit to HPC,” she said.

At the completion of Phase 2 in November 2017, HealthAlliance must create a sustainability plan. McKinnon said, “I’m confident we will show great strides. We’re collecting an incredibly robust dataset, which we will dissect and put real numbers together to demonstrate cost savings. It will be in the insurance companies’ best interest to offer to cover these services.”

McKinnon said, “This area of the state has the largest population of behavioral health patients. Our community has the most patients at risk, high rates of poverty, cancer, smoking, aging, mortality and people with lots of medical illness. They are at risk psychologically, medically and socially.”