Gabriel Malseptic, Lauren Melby, and Kathleen Connolly
Community hospitals are essential to the Massachusetts health care system: they provide locally accessible, high-quality care at a low cost to a large share of the Commonwealth’s patients. Yet, community hospitals generally experience razor-thin operating margins, which are largely driven by lower reimbursement rates—the result of serving a disproportionate share of publically-insured patients who generally receive lower-margin services such as behavioral health care. Thus, while community hospitals have a low average case mix compared to their academic medical center counterparts, they bear the burden of caring for patients who have significant complexity that is not currently factored in to case mix adjustment. In a 2016 report published by the Massachusetts Health Policy Commission (HPC), the authors note that combined, these challenges may hinder community hospitals’ ability to invest in infrastructure, analytical capability, and care delivery innovation necessary to bridge the gap to, and ultimately perform in, risk-based population health management and alternative payment models (APMs).
Phase 2 of the HPC’s Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program assists in the transformation of Massachusetts community hospitals through targeted funding, rigorous implementation planning, and individualized, responsive technical assistance to better prepare them for APMs. Supported by CHART Phase 2—a two year, $60 million program that invests in non-profit, non-teaching Massachusetts community hospitals with low relative price—27 community hospitals are implementing at scale, payer-blind clinical programs that revolutionize care delivery for the Commonwealth’s highest risk and most vulnerable populations. In our paper, Complex Care Models to Achieve Accountable Care Readiness: Lessons from two Community Hospitals, we describe two CHART Phase 2 investment awardees, Hallmark Health System and Lowell General Hospital, serving patients with frequent utilization of emergency department (ED) and inpatient services, respectively.
In the paper, we discuss four lessons for payers, providers, advocates, researchers, and policy-makers interested in implementing hospital- and community-based care delivery programs that target patients with medical, social, and behavioral health needs. Key lessons include: the value of (1) using locally-derived data to drive initial program implementation planning and ongoing process improvement; (2) adopting enabling technologies for patient case-finding, utilization, and service delivery measurement; (3) employing multidisciplinary care teams that rely on non-medical providers to serve complex patient needs; and (4) implementing partnership strategies with community resources to improve care continuity within and outside of the hospital.
Here, we dive into two of these lessons:
Across the cohort of hospital awardees, a significant proportion of the CHART Phase 2 investment is used to fund clinical and non-clinical (e.g., data analysts, program managers) personnel. As a cornerstone of their initiatives, Hallmark Health System and Lowell General Hospital are deploying multidisciplinary care teams that are anchored by non-medical staff. With championship from senior leaders at their hospitals, community health workers (CHWs) and social workers play a central role in engaging target populations and serving patients’ needs that are not met by traditional medical services. Recruiting efforts prioritized hiring frontline staff that are culturally and linguistically aligned with the communities they serve, inherently interested in understanding a patient’s story, and new enough in their roles so as to not be encumbered by the status quo of care delivery. The overarching mantra of both teams is to meet patients “where they are,” physically, mentally, and therapeutically. Care is provided in the community or home setting—in coffee shops, under bridges, and in shelters. Care might be counseling a patient on alcohol use or family dynamics, working with a medical device vendor for better equipment, bringing toilet paper to the home, and everything in between.
Many CHART Phase 2 awardees are using part of their investment funding to subcontract with community resources, enhancing and improving patient care across the continuum. Awardees are going beyond a subcontracting relationship to develop meaningful, collaborative partnerships—thus preparing these hospitals for shared accountability for mutual patients. In Phase 2, Lowell General Hospital partners with VNAs, elder services, SNFs, and a local community health center, among others, and hosts regular community partner meetings to conduct case reviews and improve coordination of care. The practice of collaborating with community resources not only improves care and increases access to needed services; it is effective and cost efficient. These strong working relationships will become increasingly important, especially as Massachusetts progresses toward its MassHealth (Massachusetts Medicaid) Accountable Care Organization program and certifies Community Partners for behavioral health and long term services and supports.
CHART Phase 2 awardees are two-thirds of the way through their two year periods of performance. Across the cohort of awardees, hospitals are not only demonstrating impressive signals of success in their programs via improved outcomes, but also a paradigm shift in re-imagining the care continuum and role of the hospital beyond the walls of the physical building. Awardees are now engaged with the HPC in strategic planning efforts to develop sustainability plans for the most effective components of their initiatives, including innovative staffing models and collaboration with community partners. We are encouraged that through our public-private partnership in CHART, Massachusetts’ community hospitals are among the nation’s leading providers in accountable care readiness, keeping care local and accessible and advancing the Triple Aim: better care for individuals, better health for populations, and lower cost of care.
Gabriel G. Malseptic, MBA, Senior Program Officer, Strategic Investment, Massachusetts Health Policy Commission
Lauren H. Melby, MBA, MPP, Program Manager, Strategic Investment, Massachusetts Health Policy Commission
Kathleen A. Connolly, MSW, Director, Strategic Investment, Massachusetts Health Policy Commission