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. Fenway Health will pilot an initiative to reduce avoidable 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. If the pilot succeeds in improving utilization and care outcomes, Fenway plans to expand it across the organization.

The goal of the project is to help transgender and MassHealth 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 are to:

  • Reduce ER utilization and hospitalization rates by 20% for the target population by removing barriers to care, educating patients about alternatives to ER utilization, and providing comprehensive, acuity-appropriate, patient-centered care; and
  • Determine whether decrease in ER use and/or hospitalization among cohort members is directly correlated with any of the project interventions.
    • 2017-2018 Project Activities:
    • 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. For 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.
    • 2018-2019 Expected Project Activities
      • Pilot 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;
      • Build 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;
      • Continue primary care-based Medication Assisted Treatment program and provide high-acuity case management and health navigation services to persons with substance use disorder and co-occurring mental health disorders.

    Project Partners: Community Care Cooperative, Boston Healthcare for the Homeless Program, Riverside Community Care, Inc., Eastern Massachusetts Community Partners, LLC

    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