The Challenge
Providers across the continuum often work in silos, lacking the ability to coordinate care and identify patients in need of services both in and out of their centers. Community health centers in particular are affected by inadequate care coordination, ultimately affecting the quality, efficiency and cost of care.
For the Massachusetts League of Community Health Centers (Mass League), there were a myriad of reasons for their care collaboration challenges: the sheer size of the community, both by number of facilities and patients, the vast diversity of their patient population, particularly as it relates to chronic issues and social determinants of health, and insufficient funds dedicated to improving their information technology. This led to a lack of awareness of care needs and utilization among primary care providers at the CHCs and, ultimately, compromised care —oftentimes, patients would visit an emergency department (ED) unbeknownst to their providers.
The Solution
Mass League received a federal grant from the Health Resources & Services Administration (HRSA) to support their health centers with improved information technology. With this grant, Mass League’s leadership established three major goals: advance interoperability, increase use of data and enhance patient and provider experience. It was clear that these goals would combine to create not only more efficient operations, but also better care and outcomes. To accomplish this, Mass League partnered with Bamboo Health to implement Pings™, which are real-time notifications sent to care teams when their patients experience care events across the continuum.
“It’s our job to help our community health centers offer better value-based care. Considering many of their patients lack private health insurance, this is also important to Medicaid. With Pings, care managers can track patients’ journeys across the continuum far better than ever before. This saves the health centers time and reduces costly care gaps, while improving the quality of care the patient receives.”
– Susan Adams, PMP, VP, Health Informatics The Massachusetts League of Community Health Centers
The Results
In just a few months, nine of Mass League’s community health centers received 72,000 real-time Pings from 28 states, which allowed them to:
- Be informed of patients’ admissions, discharges and transfers from acute and post-acute centers, including EDs and inpatient treatment facilities, both in and out of Massachusetts
- Share relevant patient information from their primary care providers to other treating providers
- Schedule appropriate and timely follow-up appointments upon discharge to increase care quality and drive down costs
Later on, additional community health centers within The Mass League adopted Pings, which amounts to nearly 350,000 unique FQHC-attributed patients being monitored by the solution in the state.
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47%
reduction in 30-day readmissions among ED patients
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20%
reduction in 30-day readmissions among hospitalized patients
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33%
increase in hospitalized patients who received a follow-up visit within 30 days of discharge
One Community Health Center’s Perspective: Manet Community Health Center
Manet Community Health Center (Manet), a community health center and member of Mass League, serves over 20,000 patients across six primary care sites south of Boston and was one of the early adopters of Pings. The solution has allowed the organization to completely revamp its workflows and track their patients more precisely than ever. By using the solution’s high-risk and high-utilizer filters and intelligent flags, Manet gains the ability to see when patients have left the ED or hospital, particularly those who left against medical advice, and highlights those who Manet should reach out to and assess right away. Moving forward, Manet will use Pings to increase compliance with patient follow-up within seven days, which is a major priority for their ACO partner.
Historically, obtaining discharge notices quickly enough for timely follow up with patients has been challenging. But now, with Pings and our newfound level of interoperability, the process is far more efficient and immediate. We now receive demographic info in Pings upon a patient’s presentation at a different care setting, enabling us to follow-up in an appropriate and timely manner. And even though we might have 1,200 emergency discharges per week, we’re aware of them in real time and can coordinate care afterwards more effectively.
Marjanna Barber-Debois Quality Manager at Manet Community Health Center
About Mass League
The Massachusetts League of Community Health Centers (Mass League) was founded in 1972 as one of the first State Primary Care Associations (PCAs) in the country. PCAs are organized around a set of core functions and competencies that provide a framework for support and assistance to health centers and the communities they serve. Mass League assists health centers and communities with workforce development, information technology development, training and education and much more. It serves the state’s 52 community health centers (CHC) that offer 300 access sites and provide care to hundreds of thousands of patients.
About Bamboo Health
Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.
