Changing to Give Patients the Very Best Care
CHA is transforming its system to align with the Institute for Healthcare Improvement Triple Aim: improve the health of populations, enhance the patient experience of care and reduce or control the costs of care. This work is important and meaningful, and will allow us to serve our patients and communities into today’s evolving healthcare landscape.
At the heart of this work is:
- The integration of our clinical services, academic programs, and public and community health functions to meet the needs of our patients and communities.
- Creating new competencies to adapt to industry changes.
Accomplishments and Initiatives
- Spreading the Patient Centered Medical Home to all primary
care sites. As of December 2016, ten CHA medical practices had been named Level 3 Medical Homes by the NCQA, the highest national designation, and all twelve practices have received the MA Health Policy Commission's Patient Centered Medical Home PRIME Certification.
- Creating new models to deliver behavioral health care. CHA is integrating primary care and behavioral health care within its primary care practices. We are also developing a new ‘Mental Health Home' for patients with intensive mental illness that features primary care clinicians within a psychiatry site.
- An innovative care management program. These services support patients struggling with multiple chronic health conditions and who require significant care coordination to achieve better health.
- Implementing care transitions to improve patient health and rate of readmission. CHA is pioneering several best practices to improve the hospital discharge process and patient and family education to create better communication about conditions, care, and services. Our Hospital to Home program is ranked 3rd in the nation and assists patients transitioning to home after an extend stay in the hospital or rehabilitation facility.
- Elder Service Plan Expansion. In July 2015 our Elder Service Plan will expand to better serve frail elders in CHA’s MetroNorth Service Area. ESP delivers all-inclusive care and support to elders who meet the state’s definition of nursing home eligible while maintaining their independence in their own home for as long as possible.
- Building Accountable Care infrastructure to adapt to new financial models that use global payments, allowing CHA to grow and accept new patients.
- Leveraging the system’s strong community linkages to maintain access to care, motivate healthy behaviors, and lead efforts to address complex community health issues. This will help us integrate prevention and public and community health with primary care.