Impact

When Dr. Boutwell leads hospitals on this care delivery transformation journey, teams go through "Implementation coaching," actively learning the method by doing the work. She meets teams where they are. Her ability to inspire problem solving, persistence, and innovation among members at all levels of the organization is incredible. She challenges hospitals to build and strengthen their skills in team building, quality improvement, analytics, and change management. She trains teams to challenge assumptions and be bold - to try new processes and pathways knowing that the system as designed does not meet these patients' needs. A critical factor to success in all of Dr. Boutwell's methods is for teams to case conference with inter-disciplinary partners to discuss and brainstorm solutions for patients. Dr. Boutwell helps teams how to conduct fruitful case conferences that catalyze a can do - will not give up spirit. Everyone involved, from the physician champions to the community health workers to partners in the community, fully appreciate the merits of problem solving and persistence and will take these abilities to other projects and other roles in their careers. This work is one part quality improvement and 10 parts system transformation and what is needed in healthcare today. Dr. Boutwell is preparing hospital front line team members and leaders across the industry to not just improve quality and patient throughput, she is preparing us and challenging us to build a new system where ALL patients receive the care they need.

Dr. Boutwell provided the expertise and leadership to the frontline clinical and operational Action Teams. She led the teams in the plenary sessions that had anywhere from 7-12 teams and interacted with each of these teams during the workshop breakout sessions. She observed their discussion in responding to the specific assignment, provided questions and insights to help them process their possible next steps. She was respectful of where everyone was starting from and what they all had available. She further worked with these teams on periodic calls as well as conducting site visits to meet each Action Team with their hospital executive sponsor to provide further individual guidance. The workshops have been highly rated over the last 3 series, with 100% of the participants recommending them this last year.

What is most impressive is that the MAX method could be scaled to numerous diverse sites in many communities across the state and still achieve significant results. The workshops covered both working with the MVPs in the Emergency Room and the inpatient units. Each hospital unit (ED or inpatient) had its own different context of data reporting, staffing, community partners, workflows, etc. By the end of year 3, there were 87 MAX Action teams representing 68 hospitals who had participated directly in the MAX workshops. Results among team reports show readmissions reductions of 18% in the first year

It was important for me to be able to visit as many of the hospitals as I could throughout the course of CHART Phase 2. What always struck me about those visits was how the teams at these hospitals had embraced CHART as an ethos and a source of pride. I remember attending a CHART launch event with 50 to 100 people in attendance, and while it was encouraging to see so much excitement from all levels of the organization, what really inspired me was hearing the CHART teams share stories of the patients they cared for who had benefitted from the program. Some of the patient stories were success stories, but others reflected the real and continuing challenges of individuals with mistrust of the health care system, who felt abandoned and isolated. There was such dedication of these staff members to the communities they served. Many of them were community health workers who came from the very communities they were supporting, who just didn’t give up. They believed in their patients. They said, “I am here to support you in your journey, whatever that may be. I support your health, your wellbeing, and your happiness, whatever happens,” and they would stick with those patients through all of their setbacks. Having the opportunity to see the real-life impacts of these programs and of these investments through the eyes of those team members is something that I’ll always remember and value.

I’ve known Amy’s work since 2015, first at the state level for the Massachusetts Health Policy Commission’s $110 million public investment program to develop community hospitals’ capacity to transform care delivery to succeed in value-based care. In the CHART Program, Amy applied methods she codified in the AHRQ “Hospital Guide to Reducing Medicaid Readmissions” in coaching teams through a two-year period of transformation to address the root causes at play in each of 27 Massachusetts hospitals. The Health Policy Commission reported in its final evaluation that 100% of CHART teams achieved their delivery system transformation goals, and over 80% of teams achieved their measurable utilization reduction goals. These methods were notable in specifically addressing and enhancing equity: target populations were all payer-blind and defined by high rates and numbers of readmissions, yielding populations not often focused on at that time, including patients with active substance use disorder, patients with comorbid behavioral health conditions, and patients with a history of recurrent acute care utilization.

CHART Phase 2 allowed us to expand integrated care to a true collaborative care program across four distinct medical groups and gave us a lot of vital data to fine-tune the delivery of behavioral health services. Due to the severe shortage of psychiatry consultation in the greater Plymouth area, we developed a model in which a dedicated psychiatrist supervised a cohort of nurse practitioners. We used this model to expand into both evaluating and treating patients in the emergency department (ED). Having a behavioral health team in the ED allowed us to not only break down the silos between us and ED clinicians, but also to develop true teamwork and shared ownership.

CHART Phase 2 also allowed us to take a detailed look at a very costly, high-utilization patient population (i.e., the dually insured Medicare and MassHealth population). We learned that face-to-face initial contact is much more effective for this population than phone calls. We also learned that patients were relying on the ED for what otherwise could be accomplished at an outpatient visit because of all of the psychosocial challenges they faced in being able to keep appointments during regular business hours

We learned how to utilize and maximize existing partnerships in the community — i.e., the school system, the drug courts, the police departments — to both expand the continuum of care and to co-develop programs, such as the Plymouth County Outreach program which now serves 28 towns

The CHART Phase 2 efforts led to a decrease in ED revisits, and therefore we began exploring scaling our processes to our sister hospitals, Beth Israel Deaconess-Milton Hospital and Beth Israel Deaconess-Needham Hospital. This new partnership with the ED staff allowed us a chance to start medication for addiction treatment (MAT) in the ED through the HPC SHIFT-Care Investment Program. We continue to utilize other facets of CHART Phase 2 as we embark on collaborative efforts with Tufts Health Plan through the MassHealth Accountable Care Organization (ACO) program, and they are particularly interested in our organic and constantly evolving multidisciplinary care plans for patients with high utilization, which we developed under the CHART program

We are profoundly grateful for CHART and we continue to think outside the box as we care for our populations

Everyone thinks that innovation is a robot or a laser or a new app, but the innovation of CHART was compassion. The CHART programs oriented care to be delivered where people actually were — whether that was a Dunkin Donuts, a homeless shelter, a church basement, or a patient’s home. Wherever these patients were, CHART went with them. The people on the ground doing this work were nurses, community health workers, social workers. CHART, at its core, was an investment in compassionate people. It was an investment in staff who knew and were committed to the communities they were serving. This investment helped to build and support a workforce with experience in this model of care that became the foundation for the MassHealth ACO program and for many other initiatives both within the HPC and across the Commonwealth.

MAX teams build a new care delivery process for MVPs in real-time. They used data to inform their work, but more importantly, MAX teams got to work improving patient care and building new effective partnerships and services from day one. Teams tracked their total MVP population, they measured the patients they served in the new care process. They reviewed this information on a weekly basis, always asking, how can we do better? What is the next step we can take? Data empowered teams at every step of the MAX. This is the future of delivery system transformation at the local, state, and national level. It’s been incredible to see the power of data-informed, rapid cycle continuous improvement in action all across New York State. The MAX is the epitome of what DSRIP is all about.

NY State Medicaid Director

I wanted to thank you all for a great visit yesterday! I also wanted to share that the two Vice Presidents that were in attendance both went down to the CEO’s office during the meeting to let him know how great the program was and how impressed and proud they were of what has been accomplished so far. We obviously couldn’t have done that without your support and direction and I really wanted to let you all know how appreciative we are for this wonderful opportunity. We know there is more work to be done, but are so happy that we are already serving our patients better in such a short time. We are also grateful that this experience has allowed us to strengthen our relationships with our community partners.