• Affiliated With

    • Beth Israel Deaconess Medical Center
    • MassGeneral Hospital for Children
    • Harvard Medical School Teaching Hospital

CHA-Gold Innovation Fellowship Program

A professional development opportunity for early and mid-career CHA clinical leaders

Healthcare service delivery is transforming. Paradigms are shifting:

  • from a mandate to deliver high volumes of care to a mandate to create high value in care
  • from individual providers to team-based care
  • from the care of individual patients to the care of populations and communities
  • from care provided in professional silos and discrete venues to care integrated across the continuum
  • from a focus on processes controlled by healthcare providers to a focus on outcomes that matter to patients
  • from healthcare providers doing TO and FOR patients to healthcare teams partnering WITH people seeking to improve their health and well-being

Healthcare systems need a new generation of clinical leaders with new knowledge, skills, and dispositions. The CHA Center for Professional Development (in partnership with the Arnold P. Gold Foundation) announces a continuing education opportunity for emerging CHA leaders engaged in institutional transformation. The Innovation Fellowship is a one-year experience designed to introduce fellows to the art and science of healthcare quality improvement and to help leaders cultivate the necessary knowledge, skills, dispositions to partner with patients and communities to co-produce good healthcare outcomes. Fellows will be invited to extend their fellowship into a second year with more limited financial support and an expanded focus on teaching and mentoring of others. A recently published paper (included as an attachment with this invitation) written by the fellowship directors describes a framework for co-producing healthcare services that shapes the fellowship curriculum.

The fellowship is co-directed by Dr. Maren Batalden and her father, Dr. Paul Batalden. Maren Batalden has been a practicing hospitalist physician at CHA for 13 years. She is well-regarded by students and residents as a committed and creative educator and currently serves as CHA’s Associate Director for Graduate Medical Education. She is also an institutional leader in quality improvement at CHA and holds the position of Associate Chief Quality Officer and Director of Medical Management for the Accountable Care Organization. Paul Batalden is an emeritus Professor of Pediatrics, Community and Family Medicine at The Dartmouth Institute for Health Policy and Clinical Practice and Professor of Quality Improvement and Health and Welfare Leadership at Jönköping University in Sweden. Paul was a founding member of the Institute for Health Care Improvement (IHI) and has a long track record of developing educational initiatives for health professionals in the United States Veterans Administration, with the ACGME, and for the United Kingdom’s National Health Service.

Who is eligible to apply?

All health professionals from medicine, nursing, and other clinical disciplines who have finished their primary professional preparation and are employed as clinicians and/or administrative leaders at the Cambridge Health Alliance are welcome to apply. Competitive applicants will have designated leadership responsibility for an initiative aligned with our CHA institutional strategic direction. Ideal fellowship projects will not be new initiatives, but rather initiatives already commissioned by the institution.

The fellowship runs from January through December. A call for submissions will be sent out early in July. If you have any questions, please contact cpd@challiance.org.



2017 Fellows

Nicholas Carson

Co-Producing Health Decisions for Families at the Interface of Behavioral Health and Primary Care

 “Integrated care” is a healthcare approach that embeds mental health providers in primary care settings to provide timely consultation to families. Integration care is listed in CHA’s “2020 Areas of Focus” and is supported by the Patient Protection and Affordable Care Act. Such innovative approaches to whole population systems of care are especially important for low-income youth and families, who often suffer poor access to mental health services and low quality treatment once they reach care. These are predominantly the families we serve at CHA. Much research now shows that prevention and early intervention in pediatric behavioral health care lead to health and cost benefits down the road. My CHA-Gold Innovation project aims to engage clinicians, patients and families in the co-production of a successful model of child psychiatry integration that provides families with the best experience of care. While plans for child psychiatry integration at CHA are coalescing quickly, pediatricians are expressing concern over difficulties accessing high quality and readily available consultation. My fellowship year will engage families with mental health need who are receiving primary care at CHA in a discussion of our plans for integration. We will use in-depth interviews and local Family Advisory Groups at CHA to engage these families. Referrals to mental health are never simple and low-income families face many barriers to reaching good mental health care. We will consider new uses of the electronic health record (EHR) and other technologies to give families the information they prioritize in understanding mental health treatment and achieving the best health outcomes for their children.

Serena Hsiou-Ling Chao

Improving Dementia Care in the CHA House Calls Program

My project is focused on improving care provided by the CHA House Calls team to patients with dementia, their family members, and their caregivers. My main goals are to 1) enhance health care provider’s management of demented patients’ behavioral symptoms and progressive clinical decline; 2) alleviate caregiver stress by systematically connecting families and caregivers with appropriate community services; and 3) reduce the risk of demented patients receiving harmful aggressive medical interventions that have little hope of improving quality or quantity of life through engagement of all team members—including families and caregivers—in the creation of shared, realistic goals of care. I plan to target three separate groups for dementia-related education: 1) patients and their families/caregivers; 2) House Calls clinical staff; and 3) staff at the two assisted living facilities operated by the VNA of Eastern Massachusetts (in Cambridge and Somerville). Potential outcome measures would be reduction in preventable ER visits and hospitalizations and decreased family/caregiver self-rated stress. Process measures would include increased referrals to community services, increased percentage of patients with DNR/DNI status on completed MOLST orders, and increased referrals to palliative care and/or hospice depending on the patient’s needs, preferences, and stage of disease. 

Ellie Grossman

Improving entry into treatment for opioid use disorder at CHA

CHA’s local communities have been deeply affected by the increasing prevalence of opioid use disorder – with many people touched by overdose deaths among friends or family, or seeing the life dysfunction experienced by people with untreated disease. Patients with addiction often have chaos in their daily lives and deep ambivalence about seeking treatment, so it is critical for a health-care system to be able to get them into treatment quickly when they are experiencing a help-seeking moment. In recent years, we have built mental health and addiction services in primary care (which decreases stigma) and added addiction treatment capacity across CHA, but we have not yet developed a coordinated intake and navigation system across our multiple sites to help ensure that patients find the treatment setting that best meets their needs. For my 2017 Gold Foundation fellowship project, I plan to work with colleagues in primary care and addiction psychiatry, as well as CHA’s IT department, to design and build a patient-friendly central navigation system – so that patients can get quickly matched to a treatment setting and smoothly transferred from one setting to another when needed. Our system will build on the experiences of patients who have made it into treatment and told us their stories, while keeping an eye out for those who seem to experience barriers (and try to address them) – so that we can get as many patients smoothly into treatment as possible.

Fiona McCaughan

Developing a Patient-Care Team Co-management Model for Diabetes Management

Diabetes is a major contributor to disabilities: cardiovascular disease, blindness, kidney failure and lower limb amputation.  In Massachusetts more than 7% of adults have diabetes, and Black, non-Hispanic; Hispanic and Asians have a higher prevelance of diabetes.  One of our strategic initiaitves at Cambridge Health Alliance is to improve the health of our patients, specifically to improve the percentage of patients who have controlled diabetes.  We use careplans with our patients to partner in their health by engaging patients around what is important to them and their overall well-being.  We know that engaged patients are more likely to understand their health needs and treatments  and we use the careplan as a platform for this.  This project will work with patients and care providers to evaluate the care plan process from both the patients' and the providers' perspective and using one care team to try various interventions to improve the process and outcomes.  

Miriam Tepper

Planning Together:  Use of the care plan to support the health goals of adults with serious mental illness

Individuals with serious mental illnesses (SMI) such as schizophrenia face a 20-30 year mortality gap compared with the general population, an inequity thought to be due in large part to adverse health behaviors. Behavior change is hard for all of us, and even more challenging for those with SMI.  Yet behavior change in this population is possible and represents a key step in bending the curve of the mortality gap.  In this project, I will examine the use of the care plan, which is a tool in the health record which includes patients’ and providers’ stated health goals as well as patients’ identified challenges and supports in meeting these goals.  Because any provider can view the care plan and talk with patients about health goals, the care plan is an ideal tool for facilitating the kind of repeated attention to health promotion needed for adults with SMI.  Every clinical encounter, therefore, represents an opportunity to support patients in their health goals.  Our clinical team has seen repeatedly that our patients want to be healthier; they are often not so interested in talking about illness but are very interested in working on wellness.  And while there is so much in healthcare that is provider-driven, framing a clinical encounter with an open question to patients about their health goals shifts the focus of the encounter toward co-production.  This project aligns with CHA’s strategic emphasis on cross-disciplinary coordination and integration of care.  On a broader scale, addressing the institutional goal of healthier patients and communities will require the accruing of many, many individual-level behavior changes.  Using an improvement science approach, I aim to determine whether care plans have the potential to serve as a vehicle for promoting this behavior change.

Leah Zallman

Co-producing provider engagement: a novel paradigm

High levels of provider engagement and low levels of burnout are associated with improved patient experience of care, health outcomes, healthcare quality and cost of care. In 2016, recognizing the importance of provider engagement, Cambridge Health Alliance (CHA) adopted a strategic plan that underscores the importance of the workforce and declares its intention of being a great place to work. That same year, CHA conducted a survey of providers which demonstrated low levels of provider engagement. Using an improvement science approach, this project aims to examine and address the underlying causes of provider engagement. A key driver of engagement is how providers relate to other individuals (especially colleagues and leaders) at their institution. Because the framework of co-production encourages a focus on relationships, this lens may be particularly well suited to addressing low levels of provider engagement at CHA.

The project begins with a formative phase, in which the focus is on gaining a deeper understanding of the context at CHA through listening to key stakeholders and reviewing existing current data. The project then enters a developmental phase, during which the focus is to develop an approach to the problem at CHA. In this developmental phase, the focus is on engaging providers and leaders in conversations around how to improve engagement at CHA. Finally, the project enter an active phase, in which the goal is to sponsor small tests of change intended to improve the quality of relationships between leaders and providers and nurture a culture of provider engagement at CHA.




2016 Fellows

Richard Balaban

Coproducing Treatment for COPD Exacerbations: The COPD Rescue Pack

Background 

Nationwide, COPD exacerbations are responsible for more than $50 billion in medical expenditures, including over 800,000 hospitalizations. At CHA, COPD exacerbations are the cause of 15% of all Medicine service hospital admissions.

For patients, COPD exacerbations have damaging medical consequences; patients’ quality of life is impaired and patients may never return to their previous pulmonary baseline after an exacerbation.

Timely outpatient treatment of COPD exacerbations can decrease the severity of exacerbations and shorten the time to recovery.

Intervention

The COPD Rescue Pack consists of a 5-day course of oral prednisone and an antibiotic which patients self-administer at the onset of a self-diagnosed COPD exacerbation. Patients are empowered to make the critical decision of when to initiate medical therapy. By reducing barriers to timely treatment, the COPD Rescue Pack may prevent or diminish the severity of an exacerbation, thereby decreasing the likelihood of an ED visit or hospitalization.

The COPD Rescue Pack promotes a partnership between provider and an empowered patient, encouraging a shift from provider-controlled treatment to shared healthcare management.

Results

A pilot implementation at a CHA primary care site demonstrated that clinical pharmacists are capable of engaging and instructing patients to properly use the COPD Rescue Pack; while patients welcome the opportunity to self-manage their disease, and use the COPD Rescue Pack wisely and with positive effect. 

Conclusions: What do we intend to do next?

Based off the successful pilot, the COPD Rescue Pack is being implemented at CHA’s ten primary care sites and three pulmonary clinics.  A quantitative analysis will determine its effectiveness in decreasing hospital and ED utilization; a qualitative analysis will define, more broadly, how to best encourage patients to coproduce positive health care outcomes. 


Christopher Fischer

Why did we start?  

Chest pain is the second-most common reason for emergency department visits. Given the potential medical, legal, and psychological effects associated with missing the diagnosis of acute coronary syndromes, clinicians have a low threshold to admit patients for prolonged observation and advanced cardiac testing.

At CHA, there are over 1,000 annual admissions for patients with chest pain. Approximately 40% of admitted patients are discharged within 1 day without advanced cardiac testing.

We identified that there was a clear need for a clinical pathway for ED patients with chest pain that is evidence-based, sensible, best utilizes available resources, and includes patient perceptions and understanding of risks. The objective of this pathway is to identify patients who are at low enough risk of acute coronary syndrome or other adverse outcomes and could be safely discharged from the emergency department.

What did we do?

We developed and are in the process of implementing a clinical pathway for the evaluation of ED patients with chest pain that includes the following components:

  1. HEART Score decision aid: a validated decision aid that utilizes clinician impression of the patient's history, EKG, age, risk factors, and biomarkers obtained in the ED. This decision aid is seamlessly integrated into the electronic health record and provides real-time, point of care decision support for the ED physicians.
  2. Chest Pain Choice Shared Decision Making Tool: a validated patient-directed tool used to discuss risk stratification with patients, and engages patient in a risk-informed discussion with the ED physician that includes patient preferences.

What did we find?

  • Development and implementation of real-time clinician decision support requires close coordination of multiple stakeholders: clinicians, patients, IT, legal, researchers. Aligning the goals of all stakeholders requires significant ongoing effort.
  • Adopting validated tools to our practice environment is an iterative process (one size does not fit all), and the input of patients is vitally important.
  • Explicit discussions about risk-informed decision making are common amongst physicians, but explicit discussions about risk between clinicians and patients is less common. Patients may have different views about risk, and integration of those views into clinical decision-making requires a real-time discussion.

What does it mean?

Implementing a clinical pathway has the potential to improve care, use resources appropriately, and improve patient knowledge.

Lorky Libaridian

Co-producing Healthy Blood Pressure Through Nursing and Pharmacy Visits

Hypertension (HTN) is an important chronic disease which has significant effects on the morbidity and mortality of our patients. At CHA, we have just over 13,000 patients with HTN, approximately 30% of whom have uncontrolled HTN.  With the aim of improving HTN control across ten primary care clinics, we formed a multidisciplinary team.  Our intent was to improve our partnerships with one another as multidisciplinary healthcare professionals and to improve our partnerships with our patients.  Our strategy was to engage nurses and pharmacists more intentionally as coaches for patients with uncontrolled high blood pressure.  Our work included the utilization of new education materials designed with patients, new workflows for outreaching to and referring patients to nurses and pharmacists, and new documentation templates in the electronic medical record that encourage a co-productive approach to counseling for nurses. 

Our data suggests that our intervention has been successful in improving - incrementally but meaningfully - the percentage of CHA patients with controlled HTN.  While we are only in the preliminary stages of data analysis, it appears that at the level of the clinic there is an association between number of nursing and pharmacy coaching visits and population blood pressure control.  These visits, however, do not tell the whole story.  Two clinics increased their use of nursing and pharmacy visits and did not see an improvement in the proportion of patients with controlled blood pressure; one clinic improved population blood pressure control without increasing nursing and pharmacy visits.  We are currently interviewing nurses at various sites to help elicit a more qualitative understanding of the way in which their own approach to counseling patients has evolved to reflect the importance of partnership and co-production.   Understanding the variation between sites, both in terms of their limitations and successes, will be important in planning and spreading future improvement projects at CHA’s primary care sites.

Robert P. Marlin

Firehouse Model Community Health Worker Teams

Why did we start?

Massachusetts is preparing to certify community health workers (CHWs) for the first time and is developing regulations that would allow for reimbursement for the work completed by CHWs under a licensed clinician. At the same time, Cambridge Health Alliance (CHA) needs to expand the number of patients it cares for within its catchment area, including among vulnerable populations, while maintaining its current patient base. This project aimed to create CHW teams from among existing CHA Volunteer Health Advisors (VHAs) and mal-employed foreign-trained health professionals (FTHPs) to engage with a diverse, multilingual, vulnerable immigrant population on issues of health and healthcare and help link them to care at CHA.

What did we do?

After identifying the CHW teams, we established ourselves in locations in the CHA catchment area and at regular times that were convenient for the target population. We then made ourselves available to anyone at these locations and offered blood pressure screenings, information on signing up for health insurance/coverage, obtaining and retaining a primary care physician/team, preventive health information, and answers to general questions about healthcare. For those without insurance/coverage or primary care, we attempted to link them to services at CHA that could provide both of these.

What did we find?

In order for individual clinicians/care teams and vulnerable immigrant patients to be able to co-produce health, CHA as an institution first needs to engage with vulnerable immigrant populations at the level of the community. For this to happen, the communities we serve and CHA leadership, clinicians and staff must see the institution as belonging to and being part of the community, rather than simply serving it.

What does it mean (and what do we intend to do next)?

While the Firehouse Model CHW teams will not continue at CHA, the institution needs to re-orient its efforts at community health engagement towards having a regular physical presence in the community and our team will work with CHA to help effect this in the Department of Community Health Improvement and other divisions.

Colleen J. O’Brien

Launching an Evidence-Based Peer Recovery Program to Enhance Self-Management Skills of Adults in Primary Care

Depression and addiction correlate with poor overall health outcomes.  Outcomes improve when patients understand their condition and play an active role in their own recovery.  In 2016, CHA screened 45,000 adult primary care patients for these conditions, and identified more than 35% for follow up.   Challenges to care delivery in the conventional model, including initial engagement and retention, could be addressed by a peer recovery model.  Could providing readily-available peer support programming help bridge the gap between consumers and behavioral healthcare providers, and increase self management skills of adults?    This project trained 12 primary care mental health therapists in an internationally-adopted, evidence-based recovery model.   We then conducted a focus group to learn if the therapists, usually “experts” in mental illness, could embrace an approach that empowers patients and emphasizes lived-experience and learning from peers? Final outcomes measures will evaluate the impact of the groups on participant hopefulness, self-advocacy, and overall health status.   Lessons learned during the training and implementation process may be useful in training other healthcare professionals and advancing coproduction in healthcare.