July 17, 2019

Clinical Care Innovation: Where Strategy, Collaboration and Integration Meet

Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this post, Susan Garrels, Program Director Behavioral Health and Care Continuum at Partners Population Health, shares her thoughts on solving problems by collaborating across teams. 

One of the things that gives me the most professional energy is strategically thinking about our various population health activities, identifying intersections of those interventions and mapping out ways to weave together programs that will have the highest impact for our patients, our providers and our Accountable Care Organization (ACO).

I am fortunate to be able to oversee two very important areas within our ACO: Behavioral Health Integration and Transitional Care. In our Behavioral Health programs, we focus on improved identification, treatment and monitoring for patients with Behavioral Health and/or Substance Use Disorders.  Our Transitional Care programs, which we also refer to as the “Care Continuum,” aim to deliver high-value care to Partners patients by redesigning sites-of-care into a cohesive framework of high-quality care continuum programs to meet episodic care needs in settings other than Emergency Departments (EDs) and Acute Hospitals and give them more time at home. Our Post-Acute work focuses on leveraging Skilled Nursing Facilities (SNFs) to provide short-term care for patients recovering from an illness or injury who require skilled nursing and/or skilled rehabilitation services.

For example, once patients are medically stable, no longer need to be in the hospital, and meet admission criteria, they may transition to a SNF to continue their recovery under continued professional care. A typical stay at the SNF is approximately 1-2 weeks, but SNFs also provide long-term accommodations for patients who require 24-hour care in a residential setting.

Utilizing Technology to Break Down Silos

From my prior experience working as a Social Worker in long-term and short-term Skilled Nursing Facilities, I have always been keenly aware of the need for more supports in those settings for patients with behavioral dyscontrol (abnormal, episodic, and frequently violent and uncontrollable social behavior in the absence of significant provocation) often a result of cognitive impairment, delirium, or psychiatric conditions. These symptoms and behaviors could often be alleviated with medication adjustments that require specialized knowledge, application of patient-centered behavioral interventions, or simply taking the time to understand the driver of the behavior such as unmanaged pain—which could be remedied with something as simple as giving the patient Tylenol® or repositioning them in their seat.

Unfortunately, based on its composition, it’s nearly impossible for staff at SNFs to have the expert knowledge to assess and address all the unique needs of our patients with behavioral dyscontrol. As a result, patients who are experiencing these issues are often sent to the Emergency Department, which can elicit increased anxiety, fear, anger and discomfort by putting them in an unfamiliar environment where they may potentially sit for hours surrounded by people they don’t know and who don’t know how to manage their emotions driving their behaviors.

These issues all came to mind as our population health Post-Acute care team sat down with the population health Telehealth team to brainstorm how we could improve patient care in our SNFs using telehealth.  I immediately thought of this population and how impactful it could be to utilize eConsults or leverage video technology to connect SNF providers directly to behavioral health experts in our system to help them better care for our patients with cognitive impairment and psychiatric issues. If we could enhance SNF clinicians’ comfort and skill by supporting them with population health tools, we could hope to see better quality of life for our patients and less Emergency Department and inpatient utilization.  While we start to plot out how we could do this with some of the SNFs, we’re thinking about some of the barriers we will need to address—including not having a shared medical record, how to connect to the eConsult technology, and providers in SNF’s developing a comfort level taking advice from specialists they may not know.

Working on the administrative side of clinical care redesign, we often tend to keep our heads down and work on projects within our own specific teams: behavioral health, telehealth, care continuum, etc. —but given the scope of work I oversee, as well as my clinical background, I am positioned well to think about the significant value of cross-collaboration. Collaboration is a natural part of working in teams and often happens organically within project teams. However, it is less likely to occur across different roles, departments or functions – which are areas in which it has the potential for the greatest impact. In my experience cross functional collaboration is a critical fundamental for clinical care innovation. As innovators, we should always strive to get input from diverse groups to incorporate tools, points of view, or novel ideas into our plans as we strive for even better patient intervention.


Susan received her Masters in Social Work (MSW) at Boston College and has been an LICSW for over 10 years.  She received her Bachelors of Science at Boston College in Human Development and Psychology. Upon graduating with her Masters degree she started her career working Skilled Nursing Facilities as a clinical social worker and ending as the Director of Social Work Services for short term and long term care.  During this time she developed her skills and passion for working in medical social work particularly with older adults with complicated illness and injury. 

From the SNFs, Susan went to work at Tufts Medicare Preferred where she assisted in the design support of the complex care management programs.  She provided consultation to care mangers working with complicated patients on complex psychosocial issues.  During this time, Susan also became the Program Manager for the Hospice and Palliative Care Program as well as the Dementia Program, developed in coordination with the Alzheimer’s Association.  She acted as the liaison between the Care Management department and the Behavioral Health team helping to define improved coordination and access for the TMP patients. 

Susan joined Partners in 2013 and spent time as a Patient Centered Medical Home analyst before taking over a depression project which has grown into a system-wide primary care Behavioral Health Initiative inclusive of IMPACT, iCBT, Connection to Specialty Care, Substance Use Disorder Support and many other programs to improve the identification and care of our patients with Behavioral Health and SUD in primary care.  In 2017 she expanded her scope of work at Partners to include the Care Continuum Portfolio of work such as SNF Transitional Care Management, Home Hospital, Partners Mobile Observation Unit, and many others.

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