Care Without Borders: How a New Models Can Help Provide a Better Experience

This is the second in a two-part series on coordinated care. In the first, Cynthia Davis talked about the enormous impact hospital at home programs can have on patients and their families. In this piece, Emily Young talks about how Circle Health is looking beyond traditional care models to create a better experience throughout the continuum.

Circle Health, an integrated community healthcare delivery system based in Lowell, Mass., embodies the promise to deliver an experience of complete connected care to ensure that no matter where an individual is in the continuum of health, he or she will realize the benefit that derives from a truly seamless, coordinated, and personal experience. As a member of Wellforce, we are proud of the strong and collaborative relationships we continue to strengthen with our local and regional partners. Together, we work to provide the absolute best care for those we serve.

The pandemic has highlighted the need to accelerate our population health work that was already underway. For example, having physicians on multiple electronic medical records has greatly underscored the need for us to move from data collection to a unified care plan approach where we’re all working from a common toolset for things like patient registries and care plans. This also confirms the value in bringing even more of our clinicians onto a common platform as we continue to grow, so we can provide the best care to patients regardless of their location. We are also focused on innovating our care management processes to a more population health alignment that supports health.

A unified approach

The idea of managing care across multiple locations is not easy, especially when there are different locations and modalities for care, including hospitals, physician practices, ACOs, PHOs and home care.

At Circle Health, we have been very deliberate and inclusive in planning for the transformation of our care delivery model. If there’s a silver lining to this pandemic, it’s that we’ve learned the value of collaboration and how quickly we can move when we’re all aligned and striving toward the same goal.  Over the past year, we have created and expanded a Field Paramedic program and unified our approach to care management by creating a team that acts like air traffic control to coordinate handoffs between providers, programs and sites along care pathways; and ensure effective monitoring and maintenance for complex cases. We are now building on top of these foundational elements to provide Hospital at Home care as well.

“A better experience”

Hospital at home programs have flourished in countries with single-payer health systems, but their use in the U.S. has been limited — despite compelling evidence that well-monitored, at-home care can be safer, efficient and more effective than traditional hospital care, especially for patients who are vulnerable to hospital-acquired infections and other complications of inpatient care, according to a study published in the Annals of Internal Medicine.

I’m grateful to our payer partners who understand this vision and have been very supportive of us pursuing this additional care pathway as well as great physician leaders helping to drive these changes in the delivery of care. In just six months, this initiative has helped avoid hundreds of ED visits and admissions, resulting in huge cost savings — and most importantly, helped to create a much better experience for patients.

Think beyond roles

We want to proactively address patients’ care needs before a condition escalates, and so we’re always striving to find new and innovative ways to do just that. We expect our team members to think creatively and to bring forward new concepts, workflows or technology for discussion. We’re not afraid to share assets internally — in fact, this approach has been one of the reasons we’ve been successful over the past year. For instance, a team member may have a particular title, but that doesn’t mean that they’re limited to doing just what that role within their particular team requires.

One of my favorite examples to share is that as we trained our Inbound Coordinators to help with our Field Paramedic scheduling process. They were able to proactively identify when a patient might be in a position for a Field Paramedic visit in their home rather than a visit to the ED. This example highlights our willingness to think beyond roles and responsibilities and instead focus on how we can leverage our team members in new ways and provide the best care possible to our patients.

Eliminating the “discharge”

On our patient’s behalf, we’ve eliminated the word “discharge” from our vocabulary because we strive to provide the right level of care, at the right time that it’s needed. This means we’re simply not confined by the walls of the hospital or the walls of our physician offices. Circle Health’s goal is to be the leading population health manager in the area and the best possible partner to its broad physician community. This includes fostering care management and clinical model redesign, working with payers to create new models for delivering value-based care and building Circle Health’s clinically integrated network.

Emily Young is VP of Population Health and Transformation for Circle Health, an integrated system compromised of Circle Home, Lowell General Hospital, Lowell Community Health Center and a large community of local physicians who bring together providers and organizations across the continuum of care with a shared vision for providing convenient and affordable access to high-quality preventive, primary and specialty care.