Baystate Wing Hospital hosted a gathering of health care providers, government and state health officials, and community partners to celebrate the hospital’s receipt of a $1 million grant from the Massachusetts Health Policy Commission to strengthen the support system for patients with complex medical, behavioral, and social needs in Hampden, Hampshire, and Worcester County communities, and reduce potentially avoidable hospital visits and admissions.
The grant is part of the state’s Community Hospital Acceleration, Revitalization and Transformation (CHART) Investment Program, a two-year initiative aiming to improve the effectiveness and efficiency of health care services throughout parts of the Commonwealth served by community hospitals.
The Health Policy Commission’s executive director, David Seltz, who attended the event, said, "CHART hospitals were issued a challenge: propose initiatives that will put you on a path of transformation, while meeting the critical health care needs of your community. Baystate Wing has exceeded that challenge. We look forward to continuing to partner with them and the communities they serve to build a more coordinated and affordable health care system.”
With its $1 million award, Baystate Wing’s primary goal is to reduce 30-day readmissions by 20% for patients with life-limiting conditions and/or behavioral health diagnoses in two years.
High Risk Care Team
To achieve this goal, Baystate Wing employed a High Risk Care Team (HRCT) to provide enhanced services to this target patient population in the Emergency Department (ED), in the inpatient setting, and following discharge. Enhanced services include individual care plans and working with pharmacy staff to conduct medication reconciliation and optimization.
During an inpatient stay, the HRCT participates in multidisciplinary care rounds and works with hospital staff to improve care planning while in the hospital and post-discharge. Additionally, Baystate Wing’s HRCT assists patients as they move to the next care setting – whether inpatient, primary care, visiting nurse association, or other services. Following discharge, the HRCT conducts in-home follow-up within 72 hours and engages with patients for 30 days, or longer, as necessary.
“The CHART funding is helping us take an innovative approach to identify those patients at the highest risk for re-hospitalization,” said Michael Moran, President and Chief Administrative Officer for Baystate Health’s Eastern Region, which includes Baystate Wing Hospital and the Baystate Mary Lane Outpatient Center.
“Our health care team has developed a system approach to care, which integrates behavioral health services into home care, to help address health issues and connect patients with services to help prevent unnecessary emergency department visits and hospitalizations,” he said.
Baystate Wing has seen early success in adopting the changes made by the CHART program, including strengthened working relationships with skilled nursing facilities (SNF) to coordinate CHART patient care after discharge, direct admissions into an SNF from the emergency department, and proactive outreach to practice managers at medical groups to better coordinate care and improve scheduling.
The CHART Investment Program is a four-year program that makes phased investments for certain Massachusetts community hospitals to enhance their delivery of efficient, effective care.
CHART Phase 2 awards to 28 community hospitals made a groundbreaking $60 million in investments to improve community-oriented care for patients with complex social and medical needs, and to increase access to high quality behavioral health services.