Jocelyn Carter, MD, MPH, is an internal medicine hospitalist at MGH. Dr. Carter was chosen to be one of two 2017-2018 HTL Healthcare Innovation fellows sponsored by the Aetna Foundation. For this 12-month fellowship, Dr. Carter worked on researching and developing an initiative to improve the healthcare of MGH patients and ultimately lower their risk of readmission.
This initiative, “Implementing Community Health Worker- Patient Pairings at the Time of Hospital Discharge”, was inspired by prior research by Dr. Carter and her team. In a previous study conducted by Dr. Carter from January 2012 to January 2016, 846 patient participants were asked about their healthcare experience throughout their time at MGH. The study uncovered similarities in patients with chronic disorders who did or did not return to the hospital within the month.
Dr. Carter found that major factors in 30-day re-admissions had to do with the patients’ own behavioral issues interfering with their ability to continue recovery on their own. These hindrances in the patients’ lives were outside the hospital’s control: things like lack of transportation, financial issues, and prior authorizations. With this in mind, Dr. Carter created her initiative to pair high-risk patients with community health workers (CHWs) to improve adherence to their care plans.
In the CHW C-CAT initiative, CHWs accompany patients to medical appointments, provide psycho-social support, and help patients successfully navigate the healthcare system. Ultimately, they act as a trusted contact and guide for patients managing and coping with acute and chronic illnesses outside of the hospital. While improving healthcare transitions as a whole, preliminary outcomes have demonstrated improved outcomes and reduced 30-day re-admissions. Moving forward. Dr. Carter and her team are integrating a digital platform into the the CHW C-CAT care delivery in order to better meet patients where they are. Preventable re-admissions account for 15 to 20 percent of all re-admissions and cost roughly $8 billion to $15 billion each year.
Dr. Carter has bore witness to both the challenging and the rewarding aspects of healthcare innovation. She notes that one of the biggest challenges is staying focused on making changes that demonstrate return on investment and provide value to the healthcare system as a whole. Almost any system could be improved, but just because something can be done about it, should it? Decisions should be based on initiatives that have generated improved outcomes and can be supported by sound metrics.
Dr. Carter predicts that higher quality and lower cost medicine will continue to be an area of major interest for healthcare systems and all stakeholders in healthcare. Thinking about innovations that improve efficiency, reduce administrative burden and improve patient-provider communication will be key. In reference to technology innovation, Dr. Carter emphasizes that healthcare organizations will continue to move toward integration of artificial intelligence enabled data monitoring to heighten the value of provider encounters and clinical assessments.