Jocelyn Carter, MD
Innovation Fellow Project | 2017

As a practicing internal medicine hospitalist at MGH, Dr. Carter noticed a common trend of patients with chronic disease being readmitted within 30-days of a previous hospital discharge. This led her to wonder about home life after hospital discharge. Based on her investigation of 850+ patients surveyed during hospitalization, Dr. Carter identified a spectrum of reasons for readmission that were mostly non-clinical. During her time as a 2017-2018 HTL Aetna Foundation Healthcare Innovation Research Fellow, Dr. Carter studied the impact of pairing patients at high-risk for readmission with community health workers at the time of hospital discharge. Primary outcomes of this work have demonstrated reduced 30-day readmission rates, decreased missed outpatient appointments, and decreased emergency department visits.

During her HTL fellowship, Dr. Carter designed a randomized control trial with her DGIM research mentors to test her theory and acquired the leadership and innovation skills she needed to win approval from hospital leadership for a permanent program. The result was the launch of the Clinical Care Transitions (C-CAT) Initiative, which has served more than 650 patients since its inception in 2017.

In addition, in 2020, Dr Carter won a 5-year, $1 million K23 award from the National Institutes of Health (NIH) that will fund a second clinical trial to assess the effectiveness of community health workers in reducing readmissions among heart patients.