Public Health Partnership at Cambridge Health Alliance

Cambridge Health Alliance
Cambridge, MA
229 Beds

Cambridge Health Alliance is an integrated health system that includes three hospitals, 12 primary care practices and numerous specialty centers. Cambridge Health Alliance also provides public health services to the city of Cambridge.

The Problem
Cambridge Health Alliance implemented several public health community programs to address chronic disease management. (1)The Childhood Asthma Program involves a collaboration of Cambridge Health Alliance with pediatricians, school nurses and local public health departments. (2) Cambridge Health Alliance developed a central¬ized complex care management team that interacts with patients extensively in the community. (3) Cambridge Health Alliance's Institute for Community Health and the Cambridge Health Department partnered to prevent obesity.

The Solution
Asthma: A web-based registry for pediatric asthma patients was developed. The information is shared with parents and, with parental permission, school nurses, emergency departments, primary care physicians and community health workers. The registry tracks treatments and outcomes and provides decision support prompts. Children are grouped according to asthma severity. The care team works with patients and their families to develop an asthma action plan and provide education. Cambridge Health Alliance also provides school-based peer groups and has developed online tools and resources to support patients and families. Additionally, a nurse and community health worker from the Cambridge Health Department Healthy Homes project conducts home visits to assess environmental triggers and help asthma-proof the home.
Centralized care: The centralized complex care management program provides a multidisciplinary team of nurses, community health workers and social workers to engage high-risk and chronically ill patients in care and help them with a variety of clinical and nonclinical tasks, such as transportation, housing and child care. These tasks may sound simple, but they are often very difficult for this population and can mean the difference between a well-managed disease and significant complications.
Obesity: Cambridge Health Alliance has long supported obesity prevention in the community through its partnerships with the Institute for Community Health, city leadership and local health and school departments. Community liaisons work with community organizations to develop programming and support policy Cambridge Health Alliance, while volunteer health advisors provide education on diabetes prevention at community events and local churches.

The Result
Asthma: From 2002 to 2009, admissions for pediatric asthma fell by 45 percent, and pediatric emergency department visits fell by 50 percent. The return on investment has been $4 for every $1 invested in the program.
Centralized care: The centralized complex care management program has generated a 5:1 return on investment over its first six months of operation.
Obesity: In Cambridge, the proportion of children with healthy weight improved from 61 percent in 2004 to 62.4 percent in 2007, and the overall prevalence of obesity among a cohort of monitored children decreased by 2.2 percentage points (p < 0.05) from 20.2 percent to 18 percent. From 2004 to 2007, almost a quarter (24 percent) of children who were obese dropped to the overweight category, while 40 percent of children who were overweight moved into the healthy weight category.

Lessons Learned
Asthma: The asthma registry helps the care team proactively manage and coordinate asthma care. It also equips providers with data to identify and measure how well they are managing asthma patients. Having access to this type of data was extremely motivating for physicians.
Centralized care: The centralized complex care management team has reached out to patients in the communities where they live by using electronic medical record data to target the highest risk pa-tients. These patients are already incurring the highest health care costs or are predicted to have the highest costs.
Obesity: To curtail the obesity epidemic at the community level, strong relationships with community organizations, public health agencies, schools and city planners are required.

Contact Information
Karen Hacker, MD, MPH
617-499-6681
khacker@challiance.org

This case study was originally featured in the HPOE guide: 'Engaging Health Care Users: A Framework for Healthy Individuals and Communities,' published January, 2013.