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Date: 12/18/2015
WESTFIELD – Baystate Noble has received a $1.2 million grant from the Massachusetts Health Policy Commission. A formal presentation took place at Baystate Noble on Dec. 11.
The Community Hospital Acceleration Revitalization and Transformation (CHART) grant will be used to reduce patient readmissions after being discharged and to create a special team to provide care and counsel after a patient is released, according to Kelley Crowley, LICSW, Director of Behavioral Health and Clinical Investment Operator. The grant will cover a two-year long initiative.
The team will be made up of three nurse managers, three social workers and one care coordinator that will work seven days a week. The goal of the team is to help patients understand discharge instructions better and to prevent avoidable readmissions into the hospital.
“Patients come to the hospital because they’re sick. When they go home, they’re not 100 percent. They’re a little better, but we expect them to understand all of their discharge instructions...” Crowley said. “We need to do things differently.”
To avoid the chaos that can surround a discharge, the team will be responsible for going over the instructions again with a patient in a quieter setting, allowing the patient to ask questions and the staff to help educate.
Crowley and her team have identified patients who are at risk for a readmission and will be proactive by checking in regularly.
“The bulk of the work is going to be done when the patient leaves, and that’s what’s new. When you work in a hospital and a patient discharges, you say, ‘We’ve done all we can do. You need to move onto the next step,’” Crowley said. “We’re not going to do that. We’re going to break down the silos a bit, and part of this team is going out to the patient’s home. We’re going to make phone calls. We’re going to go to the nursing home, and the nursing home is going to call this team and say, ‘Mr. Smith is acting really strange. We’re thinking about taking him to the emergency room.’ And we’ll be right out there to consult with the team and offer whatever we have.”
The key, she said, is engagement and education with the patient and his or her family.
“We might not be able to keep people out of the hospital if they need to, but at least there’s this next level of care that we’re putting together that will help,” she said. “We’re going to create care plans and pull these people in, and when a patient comes in we’ll be able to pull them in, sit at a table and say we have to do this together. We’ll stick to the care plan, whatever that may be.”
The grant was awarded to Baystate Noble by the Massachusetts Health Policy Commission, which was formed in 2012. The CHART grants serve as a way for hospitals to “map to find a way forward for community hospitals,” according to Policy Director Iyah Romm.
The commission is meant to curb costs, and as part of a $60 million grant program, Romm said investing in hospitals is often times the best way to save money.
“We really believe that in many cases and in many places, you have to spend money to save money, and all across the Commonwealth, you have high value, low cost cross community providers like Baystate Noble that have been under-invested in over the years by the health care system and our Commonwealth,” Romm said.