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Continuity of Care Innovation is Closer Than You Think

Analysis  |  By Tinker Ready  
   August 25, 2016

Hospital administrators seeking solutions to continuity of care challenges but who don't know where to begin, may not realize that innovative problem solvers are nearby—maybe in their own communities.

The Massachusetts Institute of Technology is known worldwide for science and engineering, not for health services research. Now it is bringing the two together with the launch of its Health Care Delivery Innovation Competition.

The project joins a growing list of other self-described innovation efforts aimed at finding new ways to solve long-standing problems in healthcare.

For the past several years, hospitals have been appointing chief innovation officers to identify and update outdated approaches to care. They've set up programs with names such as Accelerator Zone, and iHub, which uses the web address ""

But the winners of the MIT innovation competition are doing work outside hospital doors. As facilities are held responsible for episodes of care that extend beyond discharge, they'll be looking for partners—and solutions.

Debate on Effects of Social Determinants on Hospital Readmissions Continues

They may find them in community health programs that say they have been hacking healthcare for years.

Hospital administrators who don't know where to begin, or who think innovation only involves expensive technology and high risks can start by working with groups in their own communities, such as CareOregon. This organization, which notes on its website that it has been pushing innovation since 1994, serves Medicare and Medicaid enrollees.

MIT funded the group to measure the impact of a program that addresses problems such as housing, poor nutrition or "social isolation" – the social determinants of health that contribute to a patient's illness or injury.

"Most people, when they think of social determinants, they think very far upstream," says Rose Englert, head of the group's Community Health Innovation Programs. "We are looking at it differently. What is the acute medical condition that social support can address?"

CareOregon considers social needs as much a part of a patient's treatment as prescription drugs. Recent changes in reimbursement rules allows it to use Medicaid funds to address those needs.

Key to that effort is collaboration between all the community's providers, including hospitals, Englert said.

One way health systems can contribute to and benefit from that effort would be to routinely screen patient for social needs, she says. Every hospital is different, but Englert suggests they look for ways to insert a few questions about housing or food into the existing workflow.

"If we don't know the people are food insecure, how can we address it?" she says.

The MIT announcement notes that the funds will also allow the Boston-based Commonwealth Care Alliance to test the use of financial incentives "to engage some of its highest-need, but most difficult-to-reach patients."

Toyin Ajayi, MD, the group's chief medical officer, said she thinks hospitals have been late to the innovation game. They've seen inpatient care as a kind of "mecca" of healthcare, she said.

"That is why hospitals are reeling in his new accountable care world, where they ae saying 'How can I possibly be responsible for readmissions? I don't know anything about what happens to the patient when they leave here. How can you ask me to be responsible for them 28 days from now?'"

As healthcare moves away from a hierarchical model, hospitals will be better able to address those issues by working with community innovators, Ajayi says.

"They should recognize, that in many places, we actually have a rich system of community-based and primary care support for vulnerable patients."

Tinker Ready is a contributing writer at HealthLeaders Media.

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