June 30, 2018

Innovation Incubation: Center for Population Health Grants

Two years ago, Center for Population Health, in collaboration with Health Catalyst, announced that it would be awarding a one-time Innovation Grants program, totaling $1.3 million in funding, to support innovative initiatives in health care delivery. The idea was these innovative projects would align with the goal of the Center for Population Health, to enable the Partners network to lower cost trend, increase patient care quality, and ultimate identify novel ways of improving health care delivery for patients and staff. The Innovation Grants were open to all investigators and clinical researchers affiliated or employed by Partners HealthCare or by Partners HealthCare institutions.

“Every day, clinical teams across the system come up with innovative ideas to improve how we care for our patients,” says Sree Chaguturu, MD, Chief Population Health Officer. “This program allowed us to fund some of the most promising ideas and turn them into a reality.”

Nurturing Novel Ideas

The Innovation Grants were split into two categories focused on small and large initiatives: eight Pilot Grants of $50,000 each for smaller, one-year long projects; and three Implementation Grants of $300,000 each, which would fund larger scale, two-year projects.

Lauren Geddes-Wirth, MDChairman and Medical Director of Emerson Physicians Hospital Organization (EPHO), and Donna Parsons, Clinical Project Specialist, EPHO, used their team’s Pilot Grant to investigate a new way of getting patients to follow-up and proactively schedule mammograms and colonoscopies.Innovation Grants - Water Bottle Their idea: instead of handing patients a pamphlet that would get lost or end up in the trash, what if patients were given a branded water bottle with the information neatly rolled up inside?

“It’s a little more difficult to throw out a water bottle,” says Parsons, who came up with the idea for color coded water bottles (pink for mammograms and blue for colonoscopies). In addition to reminding patients to schedule their screenings, the water bottles also served as a quick and easy way for office staff to meaningfully engage with patients and get them all the information they needed, including a list of radiologists for mammograms or gastroenterologists for colonoscopies, their locations, phone numbers, and overviews of the procedures.

“I think that for the most part people know that they need it. Lots of people have this mentality that if I don’t look it’s not there,” says Dr. Geddes-Wirth. “Some of these people haven’t had mammograms in years. But this effort helped get them in and as a result, we were able to catch four new diagnoses of breast lumps and six new diagnosis of abnormal colons.”

After a year-long evaluation, the team showed 33% of water bottle hand-outs resulted in a completed screening as well as a noticeable uptick in colonoscopies overall. Through the pilot, they also created a better method for identifying overdue patients and identified areas for improvement moving forward such as better coordinating central scheduling and increased access between primary care providers and specialists.

Other Pilot Grants included programs to:

  • Reduce readmissions for patients with COPD
  • Investigate the impact of Recovery Coaches on substance use related Emergency Department visits
  • Develop better screening methods for sleep disorders.

“We just don’t have the funding to run a project like this,” says Dr. Geddes-Wirth. “We appreciated the opportunity. We learned a lot; I think our offices learned a lot. It really got our offices engaging with both the patients and with each other.”

Scalable Solutions

The Community CAre Transition (C-CAT) Initiative was funded by one of the larger Implementation Grants. Led by MGH Department of Medicine Hospitalist, Jocelyn Carter, MD, MPH, the C-CAT utilizes a randomized control trial framework to investigate the efficacy of pairing community health workers (CHWs) with at-risk patients in reducing 30-day hospital readmissions. The C-CAT CHWs are essentially clinical champions for patients and through motivational interviewing, goal- setting and psychosocial support.

Preliminary data after 8 months demonstrates significant improvement for the 350 enrolled participants— resulting in 30% lower 30-day readmission rates for patients enrolled in the program and a 20% reduction in Emergency Department visits.

Innovation Grants - Community Health WorkersEven outside of this highly focused framework pairing C-CAT CHW’s and patients, CHWs help patients in a variety of ways. Whether assisting patients complete cumbersome paperwork, providing resources and coaching to patients, or showing up in an Uber at a patient’s home to ride with them to a primary care appointment, CHWs act as patient advocates focused on wellness. Not only does this benefit patients, but it frees up provider team time to focus on clinical care.

The Center for Population Health has been adding more CHW’s to care teams in order to support the work of our Medicaid Accountable Care Organization (ACO). With an expanded team of CHW’s, targeted projects like Dr. Carter’s that leverage CHW’s have the possibility of being scaled more broadly in the future.

“Ultimately, the Innovation Grant program was an opportunity to respect local innovation and support our mission of improving patient care while lowering costs,” says Dr. Chaguturu.

The results of all of the Innovation Grant projects will be reviewed in more detail to determine the outcomes and how these learnings can be scaled across the Partners HealthCare network.

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