Project Name: Reducing ER Visits and Hospitalizations Among Fenway Health High-Acuity Patients

Project Overview: Fenway Health is a leader in providing culturally-affirming care for people who identify as lesbian, gay, bisexual or transgender and the only health center with an LGBT focus in the Boston area. More than 40% of the center’s patients identify as LGBT; the health center currently serves more than 4,000 transgender and non-binary people and many have high-acuity needs, including behavioral health conditions that reflect and are exacerbated by pervasive discrimination in housing, healthcare, and employment experienced by members of this community. In year one, Fenway Health piloted an initiative to reduce avoidable emergency room (ER) visits and hospitalizations among its high-acuity patients with behavioral health and substance use disorder (SUD) diagnoses, with a special focus on transgender people as well as those insured by MassHealth, the Medicaid program for the state of Massachusetts. In year two, the target population was expanded to include high ER and hospital utilizers, irrespective of diagnosis or insurance type.

The overall goal of the project was to help patients with substance use disorder and behavioral health diagnoses avoid unnecessary ER utilization and hospitalizations by improving care coordination and systems of care.

Project objectives were to:

• Reduce ER utilization and hospitalization rates by 20% for the target population by facilitating easier access to services including behavioral health care, educating patients about alternatives to ER utilization, and providing comprehensive, acuity-appropriate, patient-centered care; and
• Determine whether changes in ER use and/or hospitalization among cohort members is directly correlated with any of the project interventions.

• • 2017-2018 Project Activities:
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    • Identified an eligible cohort of 450 individuals for program engagement in one or more interventions;
    • Developed processes for tailored care plans for the risk-stratified patient cohort;
    • Provided information and education to all patients on after-hours services and alternatives to Emergency Room utilization including “call us first” magnets and educational pamphlets;
    • Introduced walk-in access to behavioral health (BH) services;
    • Launched a low-barrier Medication Assisted Treatment (MAT) program in the primary care practice for those with substance use disorder;
    • Hired and trained High Acuity Medical Case Manager to work with highest risk patients;
    • Established partnership with Community Care Cooperative (C3), a MassHealth Accountable Care Organization, to coordinate services and improve the provision of step up/step down services for behavioral health; and
    • Developed mechanisms for collecting patient feedback and supporting patient engagement.
  • 2017-2018 Project Outcomes
    • On average, cohort members had two contacts (clinic visit, home visit, call, or other interaction), with an average decrease of 1 ER visit or hospitalization over the 12 month project year. A risk- stratified cohort of the most acute patients (n=114) achieved a reduction in behavioral health/substance use-related emergency department visits of 3.9% by the end of the 4th quarter;
    • Hospital admissions for behavioral health/substance services were reduced by 18.9%;
    • Walk-in behavioral health clinic provided 500 encounters to 150 unique patients, and there was a statistically significant correlation between a reduction in ER visits and use of the walk-in clinic;
    • MAT program served 80 new patients during the program period, accommodating internal and external referrals. For those patients who remained engaged in MAT over the course of the program year (70%) there were no overdose fatalities;
    • A new partnership with Access: Drug User Health Program / AIDS Action resulted in 10 new referrals of individuals who had not previously been engaged in any level of care; and
    • 58 cohort members considered at high risk for hospitalization received Care Management and care planning services from Community Care Cooperative (C3) ACO.
  • 2018-2020 Project Activities
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    • Piloted a new model of care management in which nurse care managers identify the highest-frequency ER/hospital users and engage the highest–acuity patients through care plans, clinical support, and referrals to meet their individual needs;
    • Built on the success of walk-in behavioral health clinic services to increase access to urgent behavioral health care services and divert patients from the ER;
    • Continued primary care-based Medication Assisted Treatment program and provided high-acuity case management and health navigation services to persons with substance use disorder and co-occurring mental health disorders; and
    • To streamline services and reduce barriers to care for those patients at greatest risk, piloted new dual intake processes and workflows for MAT and behavioral services offered through the Addiction Recovery and Wellness Program (ARWP).
  • 2018-2020 Project Outcomes
    • In year two, 286 patients participated in the project. The walk-in behavioral health clinic provided 618 encounters to 135 unique patients;
    • Fenway’s MAT program grew steadily throughout the duration of the project period and maintained retention rates of approximately 75%. In year two, 151 unique patients utilized MAT services 1,322 times. Despite increased risk levels for new patients, the program reported zero overdose fatalities among patients actively engaged in care;
    • Overall, both ED and hospital utilization improved for the project cohort. On average, participating patients had 1.8 ER visits post-intervention compared to 3.5 pre-intervention. Participating patients were hospitalized 1.3 times post-intervention compared to 2.2 times pre-intervention. Patients who had visited the ER or hospital at least five times in the previous twelve months had the greatest reduction in ER usage; this group had an average of 3.3 ER visits post-intervention compared to approximately 6 pre-intervention;
    • Continued partnership with AIDS Action Committee, including participation by Access core team members in Fenway’s weekly Risk Rounds, helped to facilitate early entry to MAT services and bridge gaps in care and treatment; and
    • The onset of the COVID-19 pandemic necessitated that the MAT/BH dual intake pilot end early, limiting the total number of participants; the process was piloted with ten patients. Six patients who participated in the dual intake pilot (60%) went on to receive one or more behavioral health or ARWP support services. In contrast, among 30 patients who did not participate in the dual intake pilot but received MAT intakes during the same period, only nine patients (30%) went on to complete a behavioral health intake, and seven (23%) continued on to receive services following their initial intake.

  Project Partners: Community Care Cooperative, Boston Healthcare for the Homeless Program, Riverside Community Care, Inc., Eastern Massachusetts Community Partners, LLC, Access Drug User Health/ AIDS Action

  About the Grantee

  Since 1971, Fenway Health has been working to make life healthier for the people in our neighborhood, the LGBT community, people living with HIV/AIDS and the broader population.  The Fenway Institute at Fenway Health is an interdisciplinary center for research, training, education and policy development focusing on national and international health issues. Fenway’s Sidney Borum Jr. Health Center cares for youth and young adults ages 12 to 29 who may not feel comfortable going anywhere else, including those who are LGBT or just figuring things out; homeless; struggling with substance use; or living with HIV/AIDS.  In 2013, AIDS Action Committee of Massachusetts joined the Fenway Health family, allowing both organizations to improve delivery of care and services across the state and beyond. For more information, visit www.fenwayhealth.org