At a time of countless stresses on the U.S. healthcare delivery system, the leaders of community health centers face particular challenges in tracking where, when, and how their patients receive care elsewhere, such as within hospital EDs or post-acute facilities. That information is vital to the delivery of value-based care, but obtaining that information remains a huge challenge for community health centers in populous states like Massachusetts, where the sheer number of healthcare facilities, the number of patients with chronic issues and social determinants of health, and a lack of funds dedicated to improving their information technology, pose barriers.
It is in that context that leaders at the Massachusetts League of Community Health Centers (The Mass League), one of the first State Primary Care Associations (PCAs), assists health centers with workforce development, information technology development, training and education, and more. It serves the state’s 52 community health centers (CHC) which have over 300 locations and provide care to over 1 million patients.
Recognizing that their CHCs’ ability to care for their patients was hampered by a lack of visibility into care provided to their patients elsewhere – such as hospital Emergency Departments both within and outside the state – The Mass League’s leaders used grant funding from the federal Health Resources & Services Administration (HRSA), part of HHS, to implement Pings, a an electronic notification solution from the Louisville-based Bamboo Health – a technology that sends real-time notifications to care teams when their patients experience care events in any location across the continuum.
Currently, 13 CHCs use Pings to monitor over 400,000 patient lives, with several more CHCs in the process of implementing the solution. Thanks to the Transitions of Care data provided by Pings, the CHCs were able to achieve the following outcomes:
• a 47-percent reduction in 30-day readmissions among ED patients
• a 20-percent reduction in 30-day readmissions among hospitalized patients
• a 33-percent increase in the number hospitalized patients who received a follow-up visit within 30 days of discharge
As a result of implementing the program, clinicians are being 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. Those participating in the system can now share relevant patient information from their primary care providers to other treating providers, and can schedule appropriate and timely follow-up appointments upon discharge to increase care quality and drive down costs.
Marjanna Barber-Dubois, Quality Manager for Manet Community Health Center, one of the Mass League CHCs that uses Pings, said, “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 different care settings, 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.”
Per all of this, Healthcare Innovation Editor-in-Chief Mark Hagland spoke recently with Susan Adams, vice president of health informatics at the Massachusetts League of Community Health Centers, about the initiative, and what’s been learned so far. Below are excerpts from that interview.
You are part of a network of federally qualified health centers—FQHCs, correct?
Yes, we are part of a network of PCAs and HCCNs [Primary Care Associations and Health Center Controlled Networks]. We help the health centers in Massachusetts with their government affairs, quality management, workforce development, and healthcare information technology; I direct the health IT.
Our PCA encompasses 52 health centers; under our health center network, there are 36 health centers; the two sets of health centers overlap. Some health centers have different locations, are organized differently. 52 organizations, but not all participate in the health center control network.
How long have you been in your position?
In this role as vice president of health informatics, just over two years. I’ve been in health IT for 30 years and was CIO for a large FQHC in Massachusetts for eight years.
What were the core challenges you were facing?
As a health center-controlled network, we receive federal funding to help the health centers leverage their health IT needs. And one of the goals set by the federal government was to improve interoperability; that’s a nationwide goal. It’s up to us to decide what activities we’ll involve ourselves in. I took over shortly after that goal was in place. The health centers might have had a HIN in place but weren’t receiving all the discharge summaries in the state; they were typically only receiving the notifications from their closest hospitals. That’s how we landed on Patient Ping, now Bamboo Health.
Bamboo Health has events notification alerts, which are really ADT [admissions, discharges, and transfers] alerts. Every time a patient shows up at an acute-care or post-acute care facility, the FQHC can get an alert each time. The agreement was put in place in 2020, and our first FQHCs went live with this in early 2021, and we’ve been rolling it out over time in all the network centers. My team at the health center-controlled network will inform the health centers that we have this agreement with Bamboo Health; it’s voluntary to do this.
Would any clinic leaders not want to implement this system?
Well, there is still a cost to acquiring the system; we receive a 50-percent rate, but there’s still a cost. And we have a huge movement of FQHCs moving to Epic in Massachusetts; I’ve had 14 just move to Epic. So, when you’re in the Epic world, you’re getting notifications inside their network. Nevertheless, we still have plenty of acute-care hospitals not on Epic, here in Massachusetts. And we have plenty that are on Epic who realize the value of this in any case.
Were there any technological challenges involved in the implementation?
The system is easy to get up and running. However, there are workforce challenges related to using it. There are a lot of alerts; and they have to have the staff to manage the volume of alerts. We’ve been trying to help them filter and focus their ingestion towards patients with highest acuity, or with no-show rates, and make sure those patients show up for follow-up care, to avert a readmit. One health center got 412 alerts in a week for inpatient or ED visits; so, 82 patients per day in a five-day workweek. And if you have only one care manager, that’s a lot of patients to follow up with.
Essentially, they need help with list prioritization, then, correct?
Yes. The way our model is set up is that they subscribe to a population health tool, Azara Healthcare DRVS, a central reporting repository and population health tool. So we have the alerts come back into Azara DRVS, and that gives them a worklist of all the alerts, so a care manager will see everyone who is on the list; they can see who has a follow-up appointment scheduled with a provider; can sort by diagnosis, to see who has higher acuity; and they get a robust dashboard to measure and manage their performance goals. If they have a goal that every patient admitted needs to be seen within a week, they’ll know where they are.
What have been the biggest learnings so far?
The data speaks for itself; we’ve been able to compare those who have the Bamboo solution and those not. The data we look at is two sets, the first set being their ED readmission rates and inpatient readmission rates. In their 30-day ED visit readmission rates, we’ve seen an 87-percent reduction. And then for those using Bamboo versus not. And on the inpatient readmission, it was a 25-percent reduction on a 30-day admission rate.
How would you articulate the difference?
It’s having the tools available for your care manager to really track the journey of the patient across their continuum of care. It’s knowing where your patient has been going and is going. And you can wait for a CCDA document from a discharge summary, but it can be 100 pages long, and for a provider to have to go through that, is a real challenge. So the alerting program: there are no surprises to the provider; the provider can see in a quick look, what has happened to the patient. And the care manager can pull out the pertinent information for the provider to know—why the patient was just in the ED, for example. And the second set of data we look at is the patient being scheduled for a follow-up visit, and then we can see whether they showed up for that follow-up visit or not. We’re seeing a 31-percent increase of patients receiving a follow-up visit when the health centers use this solution. And did they show up for it? And there’s a reduction in no-show rates, as staffers at the health centers do the follow-up by phone, with patients.
These patients are leading very unstable lives sometimes, so the reminders can really help, correct?
Yes, and the Azara platform has the social drivers in there as well, so the care manager can see the social drivers in the platform, or screen them at the time, to make sure they come in for that visit.
What would you say to health IT leaders nationwide about implementing and using tools like these?
Any healthcare organization wants to reduce costs and improve patient outcomes. This is a tool that will help do all those things. Getting real-time alerts is far more productive than waiting for a discharge summary that may never come. You can improve patient outcomes while at the same reducing costs.
Is there anything else that you’d like to add?
We’re sharing data with 14 health centers, and encompassing 400,000 patient lives, about to rise to 450,000 patient lives. My goal is to get it to the 1 million residents that FQHCs care for in Massachusetts. That’s one out of seven residents. And 30 million patients are served by community health centers nationwide; that’s one in 11 patients nationwide.
