Southcoast Health creates and successfully implements innovative care model to treat patients with complex medical histories

Program results show 26 percent reduction in 30-day readmission rates of high-utilization patients

NEW BEDFORD, Mass. — Southcoast Health announced today that it has reduced 30-day readmissions by 26 percent for patients with a personal history of recurrent inpatient utilization and reduced 30-day Emergency Department (ED) revisits by 14 percent for patients with a personal history of recurrent ED utilization in preliminary data analysis. These results were achieved through a new care model called MyCare Teams, which Southcoast Health created and implemented with the assistance of the Massachusetts Health Policy Commission’s CHART-2 grant.

During the program’s duration from 2016 to 2018, more than 2,000 individual patients received services with 50,000 patient encounters provided by the MyCare Teams. The data and lessons learned through those encounters helped Southcoast Health better understand the eligible patient populations and their needs.

“Over two years, we achieved phenomenal results for our patients,” said Patrick Gannon, Chief Quality Officer and CHART Operational Investment Director at Southcoast Health. “The participating patients and the entire health system, not just our hospitals, are beneficiaries of the CHART initiative. We’ve learned how to accelerate, revitalize and transform healthcare for patients who are the highest and oftentimes most chronic utilizers of inpatient and emergency department services. Traditional care models do not work for the CHART-eligible patients; we had to create something new and innovative.”

“Our partnership with community hospitals is a critical part of the Health Policy Commission’s efforts to achieve the Commonwealth’s cost containment and quality improvement goals,” says David Seltz, Executive Director of the Health Policy Commission. “CHART hospitals were issued a challenge: Propose initiatives that will put you on a path of transformation, while meeting critical health care needs of your community. As the preliminary data released today shows, Southcoast Health has met that challenge. Southcoast’s results show that their program is working to achieve its goals and positively impacting its patients. We look forward to continuing to partner with Southcoast Health and the communities it serves to build a more coordinated and affordable health care system.”

According to the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality, 20 percent of the population accounts for 80 percent of total healthcare expenditures.

Southcoast Health created multidisciplinary care teams (including physician, mid-level prescriber, registered nurse, social worker, nurse care manager, community health worker, clinical pharmacist, and a community resource specialist) to care for patients. Teams provided intensive medical and behavioral health services, linkages to outpatient treatment providers, palliative care, diabetes education, and assistance accessing social services support.
“We have since converted the lessons learned during CHART into an Accountable Care model for care navigation,” said Lori Dakin, Executive Director of Behavioral Health at St. Luke’s Hospital for Southcoast Health. “We are better able to treat patients across the continuum of care, which makes for a more efficient and effective healthcare experience for high-risk patients. These are patients that often fall between the cracks. We learned that revitalization is hard, but necessary. We see firsthand what transforming a patient’s care can mean for every life we touch.”

Southcoast Health’s electronic health record system, Epic, provided the digital infrastructure and technological advancements to help collect and analyze patient data. The CHART leadership team also utilized community health workers as part of the MyCare Teams.

“Once a patient engaged with the MyCare Teams, a key to success rests with encouragement for the patient to tell their story to a listening ear. The ability for a patient to release the stories that inhibit their ability to function is a way to start the healing process. We let the patient develop their goals to foster engagement and trust. We learned that offering help in segments is more successful than too much, too fast,” said Gannon.

Southcoast Health has converted the best practices from CHART into an expanded, ambulatory-facing care navigation program that will utilize several functions learned through the process.