In Your Neighborhood

Integrating wellness, prevention and care at home of the patient

New community health team is up and running in Pawtucket, using Blackstone Valley’s health IT system

Photo by Scott Kingsley

Christine Grey, right, the COO of Blackstone Valley Community Health Care, and the team at the community health center that has developed a patient engagement app for its members.

By Richard Asinof
Posted 10/13/14
Innovative health approaches are moving ahead in Rhode Island, transforming the landscape and developing a community-based approach to health care, wellness and prevention. The community health team approach now underway in Pawtucket is a great example of partnership between community health centers and hospital systems to effect patient-directed care.
When will there be a comprehensive mapping process of health innovation in Rhode Island? How can similar efforts – the community health team in Pawtucket and South County, and the community health workers at Clinica Esperanza – share and collaborate and learn from each other? Who will serve as the next head of the R.I. Executive Office of Health and Human Services? Do either of the gubernatorial candidates – Fung or Raimondo – have a choice in mind? Has the R.I. General Assembly been briefed on health innovation initiatives and policies? Who should be involved in that briefing?
The annual summit of the R.I. Business Group on Health will feature all the grand poobahs of the state’s health care delivery system: the CEOs of the commercial health insurers [minus Neighborhood Health Care of Rhode Island], the CEOs of Care New England, Lifespan and Care New England, the CEO of Coastal Medical, the co-director of CSI-RI, and the head of the R.I. Quality Institute, the director of CVS Minute Clinics, and a “reactor” panel featuring the medical director from Blue Cross & Blue Shield, the benefits director for Brown University, and a senior assistant vice president from Amica.
What’s missing from the conversation? Consumers, patients, nurses, community advocates, public health practitioners.

PAWTUCKET – The market – and the community – wait for no one, to paraphrase a comment often voiced by Dennis Keefe, president and CEO of Care New England.

A delegation from Rhode Island will be meeting with federal officials on Oct. 15 to promote their State Innovation Model plan in hopes of being awarded more than $58 million in new federal funds to transform the state’s health care delivery system, with a greater focus on community health, prevention and public health.

But, even before Rhode Island hears back from officials at the Centers for Medicare and Medicaid Services on the grant, community initiatives are moving ahead with a series of innovative approaches, with a focus on public health outcomes and prevention.

In Central Falls, a new school-based health clinic at Central Falls High School will open on Oct. 27, a precursor to efforts to develop a neighborhood health station in the square-mile city, where health, prevention and wellness services would all be available for the whole community in one place – wellness, prevention, primary care, urgent care, home visitation and behavioral health. [See link to ConvergenceRI articles below.]

The plan is being championed by Dr. Michael Fine, director of the R.I. Department of Health, and could emerge as a key component of any State Innovation Model moving forward.

Another innovation – community health teams – is underway as part of the R.I. Chronic Care Sustainability Initiative, recently rebranded as the Care Transformation Collaborative. 

Under the new initiative, payers – including Blue Cross & Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island, and UnitedHealthcare's Medicaid program – provide lists of high utilizers to community health centers and practices that are members, and in turn, community health workers visit these patients to assist them with their care.

The community health team is up and running in Pawtucket, and a second is being planned in South County. Although this approach was included as part of the SIM grant, the work is already underway.

ConvergenceRI spoke with Christine Grey, the chief operating officer at Blackstone Valley Community Health Care, talking about the details of the community health team initiative. Grey had just finished a presentation at the Radisson Hotel in Warwick on Oct. 9, “Patient Engagement Using Technology,” part of the conference organized by CSI-RI entitled, “The Primary Care Team: The Future is Now.”

The half-day conference, which filled the hotel’s ballroom, marked a decade of growth for CSI-RI, which has grown from a pilot program to a planned expansion to include some 48 primary care practices with 300,000 Rhode Islanders. In addition, a new children’s initiative is being planned.

Community health team in Pawtucket
To date, the Pawtucket community health team appears to be working very well, with great individual stories, according to Grey. “These individual stories [of health care workers helping patients] are going to sell the success of this health team,” she said.

The community health team approach involves home visits, in-office visits, phone calls. the community health workers, or navigators, act as extenders to the primary care practice.
The team works in conjunction with the providers and nurse care managers at the practices, helping patients with social issues which may be barriers to good health so that the clinical staff can concentrate more on clinical issues.
The community health team partners with all seven CSI practices in the area, including Blackstone Valley. The community workers meet with the patient and assess the need for social services, such as assistance with transportation, childcare, health literacy, interpretation, or financial assistance. If there are behavioral health issues involved, the workers would then help the patient engage with services, either at the primary care practice or with outside resources.

Eventually, Grey continued, the community health team results will be able to show directional impact. “But I don’t know how long that will take. It’s the payers who identify the high-risk patients [and provide the lists]. We act on the lists.” Without knowing what algorithm they use, Grey continued, “I can’t say if we’ll have really great directional impact.”

There are certain diagnoses that you can’t impact, no matter their cost. “It could be a one-time cost, but no matter what we do, we’re not going to impact it.”

In the meantime, the anecdotal stories from providers and patients point to an immediate success.

Documentation
Blackstone Valley Community Health Care has been a leader in the sophisticated use of health IT at the point of care, reducing its medical cost curve by $12 million over the last four years, at the same time achieving high-rated outcomes.

As part of its involvement with the community health teams, Blackstone Valley will be using its health IT system for documentation, employing what Grey called a “really robust” care management program that features NextGen Care, formerly Mirth Care, a company acquired by NextGen in 2013.

“Blackstone is working with Mirth Care and NextGen,” Grey said. “We’re planning to use it for our community health team in Pawtucket, and we’ll use it for Blackstone.

Grey continued: “We’ve demo-ed it to CSI and to the state, and we’re hoping that they will take it up. It’s a very useful tool.” Grey indicated that CSI is investigating various products for use statewide.

In the meantime, both the Pawtucket community health team and the South County community health team will be using NextGen licenses through Blackstone Valley to document their work. “And, if we have NextGen Care available, we’ll make it available to them as well.”

Interoperability
As Care New England, Lifespan and CVS move toward the implementation of Epic as a new health IT system, ConvergenceRI asked Grey, from Blackstone’s perspective, had there been any engagement around interoperability with the new system.

“We’re still working with Lifespan and Care New England and their current systems to get full ADTs [admission discharge transmissions] as soon as possible for our patients,” she said. “When Epic comes along, we’ll cross that bridge when we get there.”

She added: “We’re hoping that it will be a more robust EHR system, and we’re hoping that it will communicate with ours.”

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