MeHI Awards $3M To Enhance Coordination Among Community Healthcare Providers & Improve Patient Care

‘Connected Communities’ Grants Aim to Address Critical Healthcare Issues Via Increased Use of Innovative Technologies

During an event at Brockton Neighborhood Health Center recently, MeHI, the Massachusetts eHealth Institute at MassTech, announced $3,038,000 in grants to drive community-level collaboration among healthcare providers using innovative technologies. The grants were made through MeHI’s Connected Communities Implementation Grant program, a statewide effort which seeks to enhance collaboration and communication among healthcare providers within a community through the use of innovative technologies, such as electronic health records and health information exchanges.

MeHI announced awards to seven Massachusetts healthcare organizations working with a total of 78 partner organizations, each receiving grants of $434,000 to support collaborative projects. Each project involves four or more organizations in a specific region, such as hospitals, physician groups, home health agencies, civic and municipal organizations, and at least one behavioral health and/or long term and post-acute care organization. Per the terms of the grant program, each project is required to address practical, measurable healthcare needs among the awarded organization’s patient population.

“By using technology to strengthen local ties, these grantees and their collaborators will be better prepared to address the critical healthcare challenges impacting Massachusetts, including combating the opioid crisis, avoiding unnecessary or recurring readmissions, and preventing adverse drug events,” said Laurance Stuntz, MeHI’s director.

The objectives of the Connected Communities Implementation Grant Program are to catalyze inter-organizational collaboration and to advance the use of interoperable electronic health records (“EHRs”) to improve healthcare and reduce healthcare costs. The Connected Communities Program started with a needs assessment, which involved interviews and roundtables with stakeholders in 15 communities across the Commonwealth. Each community’s needs were captured in Community eHealth Plans and helped shape the goals of the final grant program.

The seven organizations that will manage grants in their respective regions include [full profiles available at end of release]:

• Behavioral Health Network
  Springfield, Mass.
• Berkshire Medical Center
  Pittsfield, Mass.
• Brockton Neighborhood Health Center
  Brockton, Mass.
• Cape Cod Healthcare
  Hyannis, Mass.
• Lowell General PHO
  Lowell, Mass.
• Reliant Medical Center
  Worcester, Mass.
• Whittier Independent Practice Association (IPA)
  Newburyport, Mass.

The announcement took place at Brockton Neighborhood Health Center (BNHC), which received a Connected Communities grant for a project focused on coordinating care for patients with substance use disorders across various providers through the adoption of current health information technologies. This project will allow BNHC and its collaborating partners (High Point Treatment Center, Brockton Area Multi-Services, Inc. [BAMSI], Signature Healthcare, and Good Samaritan Medical Center) to make positive changes in a region hit hard by the opioid crisis. By streamlining coordination and planning of care among a patient’s providers, no matter where the providers are located, this project will allow better treatment to be delivered to patients battling substance abuse.

“We are collaborating to eliminate gaps in the care continuum for people suffering from opioid and other addictions,” said Sue Joss, CEO of BNHC. “By using technology to enhance communication and referrals across multiple care providers, we will increase access to services for people seeking recovery.”

The Connected Communities program is designed to build upon and complement Commonwealth-supported programs across many state agencies, both those managed by MeHI and by partner state organizations, such as the Executive Office of Health and Human Services (EOHHS), the Massachusetts Department of Public Health, and the Health Policy Commission. Previous programs include: MeHI’s HIway Implementation Grant and HIway Vendor Integration Grant programs; HPC’s CHART (Community Hospital Acceleration, Revitalization, & Transformation) program; DPH’s Prevention Wellness Trust Fund; and the federal Meaningful Use program.

“These projects highlight the strength of the Commonwealth’s healthcare delivery sector,” said Alice Moore, Undersecretary of Health at EOHHS. “They will help improve how community care is delivered, increase collaboration across healthcare providers, help reduce costs, and improve health outcomes and patient experience.”

The Connected Communities program aligns with MeHI’s charge to engage the healthcare community and catalyze the development, adoption, and effective use of digital healthcare. In particular, the program supports provider organizations that typically lack access to the necessary resources needed to implement health technology, such as behavioral health and long-term post-acute care organizations. The program provides incentives to assist eligible organizations and their community collaborators in the advanced use of interoperable EHRs to enable access to timely, clinically relevant information to improve two aspects of care coordination: 1) transitions between different settings of care, and 2) cross-setting care management among inter-organizational care team members.

The Connected Communities grants are funded via key investments made by the Commonwealth of Massachusetts through Chapter 224, the 2012 healthcare cost containment law.

Quotes from Grantees
“While Reliant Medical Group has consistently delivered very high quality care, we are excited about the enhanced opportunities that the Connected Communities Grant will present for Reliant and all of the providers in the Central Massachusetts and Metrowest communities,” said Larry Garber, MD, Medical Director for Informatics at Reliant Medical Group of Worcester, Mass. “Throughout the region, healthcare providers caring for our patients will instantly receive comprehensive medical information, whether that’s in the ER, a nursing facility or at home under the care of visiting nurses. Even paramedics summoned to a patient’s home will receive a medical summary while en route in their ambulance!”

“This grant will help support improved connectivity between our multiple electronic health records across Berkshire County, facilitating better communication between care givers at various transition of care touch points,” said Mark Snowise, MD, Medical Director of Informatics for the Physician Practices at Berkshire Health Systems in Pittsfield, Mass. “This is a great opportunity for us to continue to improve the coordination of care across Berkshire County and the state, allowing us to provide more comprehensive, cost efficient care to our patients. With the leadership of Berkshire Health Systems we are very excited to work with state in transforming how we care for patients in the electronic medical record age and how we improve communication and quality of care for our patients at such critical times in their lives.”

“The Newburyport, Amesbury and Haverhill Medical Communities are so fortunate to have received this Connecting Communities grant to the Whittier IPA,” stated Joe Heyman, MD, Chief Medical Information Officer at Whittier IPA in Newburyport, Mass. “Our Wellport Health Information Exchange will have the wherewithal to improve patient care through important alerts to physicians when the individual is experiencing a medical emergency or a hospital admission and discharge. These resources will help make sure patients are on the right medications especially when patients leave the hospital to go to a skilled nursing facility or are seen at home by a nurse from a home health agency. The grant makes it possible for our behavioral health clinicians to collaborate with other clinicians in our community. In short, this grant makes it possible to more efficiently provide higher quality care through better communication. Thanks to MeHI for making this possible.”

“Behavioral Health Network is excited to be chosen by MeHI to spearhead an effort to build an extensive, collaborative electronic communication network that includes the three largest hospitals and their community health practices in the lower Pioneer Valley,” noted Katherine B. Wilson, President and CEO at Behavioral Health Network in Springfield, Mass. “Funding from MeHI will enhance the extensive work BHN has done to date with their healthcare partners to integrate medical and behavioral health practices. This MeHI grant recognizes that providing a behavioral health service in isolation does not adequately support the overall wellness of clients shared by the behavioral health and healthcare systems. As medical conditions become more complex, ensuring that clinically meaningful communication happens between all providers is critical to improving healthcare outcomes and improved health for those in our communities. This electronically connected network will improve care coordination across multiple acuity settings, with the outcome of improving whole health for those with co-occurring medical and behavioral health concerns. BHN is excited to be working with components of the Baystate Health System, Holyoke Medical Center and Sisters of Providence Health System, as well as with the Holyoke Health Center and Pediatric Associates of Hampden County.”

"The Connected Communities Grant will enable our organization and its collaborating partners to optimize our existing care management technology. These technological improvements will allow us to streamline patient care transitions and improve cross-setting care management in a joint effort to enhance patient experience and improve outcomes,” stated Emily Young, Senior Director of Healthcare Operations at Lowell General Physician Hospital Organization.

“We are very excited to have been selected to receive the MeHI Connected Communities grant that supports healthcare IT Integration,” said Jeanne M. Fallon, MHA, Sr. Vice President and Chief Information Officer, Cape Cod Healthcare (CCHC). “The grant will help us to enhance CCHC’s Mission to coordinate and deliver the highest quality, accessible health services for all Cape Cod residents and visitors. The grant will enable healthcare IT Integration and help us to strengthen care coordination during the transition of care for patients and streamline the information pathways between Cape Cod Healthcare and Collaborating Organizations across Cape Cod.”

Grant Summaries
Behavioral Health Network

• Location: Springfield, Mass.
• Award Amount: $434,000

Project Partners (13):Brightwood Health Center, High Street Adult Health Center (Baystate), Pediatric Associates of Hampden County, Mason Square Neighborhood Health Center, High Street Health Center - Pediatrics (Baystate), Baystate Behavioral Health - Adult Psychiatry Unit, Providence Behavioral Health Hospital - Inpatient Psychiatric Unit, Baystate Wing Memorial Hospital - Psychiatric Inpatient Unit, Baystate Noble Hospital - Inpatient Psychiatric Unit, Sisters of Providence Health System - Substance Abuse Detoxification Unit, Holyoke Medical Center - Inpatient Psychiatric Unit, Holyoke (Mass.) Police Department, and Pioneer Valley Information Exchange (PVIX).

Project Summary:The primary objective of this project is to build an extensive collaborative IT infrastructure that includes all of the largest hospital systems and health centers in the Pioneer Valley. The project will bridge multiple acuity settings during transitions of care for persons with co-occurring medical and behavioral health concerns through the exchange of CCD (Continuity of Care Documents) and transmission of event triggered notifications. This grant will impact care transitions for patients presenting with a behavioral health event in primary care settings as well as in all five local Emergency Department crisis centers. Significant engagement will occur with non-TPO (Treatment, Payment, and Healthcare Operations) community stakeholders through collaboration with local police departments.

Berkshire Medical Center

• Location: Pittsfield, Mass.
• Award Amount: $434,000

Project Partners (7): Family Practice Associates, Berkshire Medical Group, Berkshire Healthcare Systems, Inc., Community Health Programs, Inc. , Berkshire Orthopedic Associates, Inc., The Brien Center for Mental Health and Substance Abuse Services, and Eastern Mountain Medical Associates, PC.

Project Summary: The goal of the Berkshire Connected Communities project is to achieve the alignment of collaborative care practice models with supporting health IT to create new opportunities for patient care and quality improvement. The project will create tools that allow clinicians to electronically receive timely hospital admission notifications and discharge summaries, and exchange services notes and care plans including behavioral health and community based health organizations. The model is intended to test care transitions and care management systems in a wide range of settings across the continuum of care with the goal of expanding it to the entire system of healthcare in the region.

Brockton Neighborhood Health Center (BNHC)

• Location: Brockton, Mass.
• Award Amount: $434,000

Project Partners (4): High Point Treatment Center, Brockton Area Multi-Services, Inc. (BAMSI), Signature Healthcare, and Good Samaritan Medical Center.

Project Summary: The primary objective for this project is a collaboration between BNHC and partners to coordinate the care of patients with substance use disorder across providers. This includes the ability to send and receive referral information electronically, including ordering referrals electronically, sharing information about the status of the referrals, sharing relevant clinical information such as medications and treatment status, and electronic transmission of care plans. Given the opioid crisis in Brockton, BNHC selected partners that collaborate to care for substance abusing patients, including substance abuse, mental health, primary care, and hospital providers.

Cape Cod Healthcare

• Location: Hyannis, Mass.
• Award Amount: $434,000

Project Partners (23): BAYADA Home Health Care, Bourne Manor Extended Care, EPOCH Senior Living of Brewster, Gosnold on Cape Cod, Gentiva Home Healthcare, Harbor Community Health Center - Hyannis, JML Care Center, Mayflower Place Nursing and Rehabilitation Center, Liberty Commons Rehabilitation and Skilled Care Center, Outer Cape Health Services, Pavilion Rehabilitation and Nursing Center, Royal of Cotuit Nursing and Rehabilitation Center, Royal Falmouth Nursing and Rehabilitation Center, Royal Megansett Nursing and Retirement Home, Royal Cape Cod Nursing & Rehabilitation Center, Spaulding Rehabilitation Hospital Cape Cod, Visiting Nurse Association of Cape Cod Home Health and Hospice, Windsor Skilled Nursing and Rehabilitation Center, Cape Cod Hospital, Falmouth Hospital, Cape Cod Hospital Centers for Behavioral Health, Community Health Center of Cape Cod, and Duffy Health Center.

Project Summary: This project will standardize the clinical and patient documentation sharing process between CCHC’s two acute care hospitals, Cape Cod and Falmouth Hospital, and the primary referral partners and post-acute providers on the Cape and Islands. The collaborating organizations involved in this initiative include many of the largest referral partners located on the Cape and Islands. These types of health care providers include Community Health Centers, Skilled Nursing Facilities, Rehabilitation facilities, Home Health Agencies and Behavioral Health providers.

Lowell General PHO

• Location: Lowell, Mass.
• Award Amount: $434,000

Project Partners (9): athenahealth, Cerner, PointClickCare, Palm Center- Genesis, Westford House - Genesis, Willow Manor - Genesis, Heritage Nursing Care Center- Genesis, D'Youville Senior Care, and D'Youville Center for Advanced Therapy.

Project Summary: The goal of Lowell General PHO’s (LGPHO) project is to develop and implement a cross-setting care management tool, implement real-time data feeds, and optimize workflows and training. The project will allow LGPHO to unify clinical information, strengthen care transitions and improve cross-setting care management between Lowell General Hospital, the Skilled Nursing Facilities, and outpatient providers (LGPHO member physicians) to reduce unnecessary readmissions, mitigate unnecessary costs and improve patient outcomes. To achieve the goal, LGPHO and its collaborating partners will leverage existing electronic medical record (EMR) data and Direct technology as well as develop and implement a single cloud-based care management tool as a central repository for pertinent clinical and social patient information that can be accessed by providers at each of the collaborating partner organizations.

Reliant Medical Center

• Location: Worcester, Mass.
• Award Amount: $434,000

Project Partners (14): AdCare Hospital, Beaumont Rehab & Skilled Nursing Center - Westborough, Family Health Center of Worcester, Holy Trinity Nursing and Rehabilitation Center, Jewish Healthcare Center, Life Care Center of Auburn, MetroWest Medical Center, Milford Regional Medical Center, Notre Dame Long Term Care Center, St. Vincent Hospital, UMass Memorial Medical Center, Vital EMS, VNA Care Network and Hospice - Worcester, and Worcester Rehabilitation & Health Care Center

Project Summary:The primary objective of Reliant Medical Center’s Connected Communities project will be to build on the current IMPACT Grant infrastructure to include first responders, behavioral health providers, hospice and the area Aging Service Access Points (ASAPs), in order to measure outcomes of improved transitions and coordination of care with a focus on automated processes. The plan is to gather real-time admission, discharge, or transfer (ADT) notifications from collaborators and then automatically send continuity of care (CCD) summary documents to those Home Health Agencies, Skilled Nursing Facilities, hospitals, and ambulance paramedics in real-time when they are about to treat one of Reliant’s patients. All of these “subscribed” ADT transmissions will act as a pilot to inform the MA HIway as it moves into the next phase of its Relationship Listing Service (RLS). Every Reliant Medical Group patient will need to be consented in advance to participate in the MA HIway through the use of electronic signature pads for Reliant’s primary care sites. All of these signed consents will be submitted electronically to the MA HIway’s RLS.

Whittier Independent Practice Association (IPA)

• Location: Newburyport, MA
• Award Amount: $434,000

Project Partners (8): Anna Jaques Hospital, Amesbury Psychological Center, Home Health VNA (including Merrimack Valley Hospice and HomeCare, Inc.), Great Lakes Caring, Country Center for Health and Rehabilitation, Pentucket Medical- Newburyport, Maplewood Center - Genesis, and Essex Inpatient Physicians.

Project Summary: The goals of this grant project are to reduce adverse drug events in patients by increasing medication reconciliations among acute and post-acute care providers, and to reduce the number of hospital readmissions through the use of alert notifications. The Wellport Health Information Exchange (HIE) contains robust clinical notes from 445 contracted clinicians, Anna Jaques Hospital (all clinical notes, lab and radiology reports), Surescripts, Quest Diagnostics, LabCorp, and Home Health VNA. Whittier IPA proposes to expand access to Wellport clinical information through its clinical portal to one behavioral health organization, two sub-acute nursing facilities (SNFs), an additional home health organization, and a large physician group that staffs nursing homes and hospices in the Merrimack Valley.

About The Massachusetts eHealth Institute
MeHI, or the Massachusetts eHealth Institute at the Massachusetts Technology Collaborative, is the state's entity for healthcare innovation, technology, and competitiveness and is responsible for advancing the dissemination of health information technology throughout Massachusetts, including the deployment of electronic health records systems in healthcare provider settings and connecting them through the Mass HIway, the statewide health information exchange. For more information, visit http://mehi.masstech.org.