In her role as an internal medicine hospitalist and researcher at Massachusetts General Hospital, Jocelyn Carter, MD, MPH, noticed a disturbing trend: a striking number of patients were readmitted within a month of discharge — often in worse shape than when they originally arrived.
“It was a mystery. I was curious about how the patient experience after leaving the hospital could be contributing to readmission.”
“They received excellent care, had excellent discharge planning and they left us in far better condition than when they arrived,” she says. “It was a mystery. I was curious about how the patient experience after leaving the hospital could be contributing to readmission.”
Preliminary evidence from the medical literature and Dr. Carter’s previous study as a researcher at the Mass General Division of General Internal Medicine (DGIM) indicated that more than 25 percent of readmissions were avoidable. Sometimes patients didn’t have transportation to the pharmacy or weren’t able to maintain their medication schedule. In other instances, they didn’t understand a key update to their care plan after discharge.
“What appeared to be consistent is that some patients didn’t have the support they needed after they left the hospital,” says Dr. Carter. “Even if we have done everything perfectly in terms of diagnosis, imaging, and therapy — not everyone understands how to take care of themselves or has the resources to do so.”
The solution, she believed, was to identify at-risk patients prior to discharge and pair them with community health workers for 30 days. Community health workers are frontline professionals who have a deep understand of the experiences, culture and unmet needs of the communities they serve. They also have expertise in locating low-cost housing, food and transportation that can help reduce poor health outcomes.
Establishing this program would, of course, require funding and an enormous amount of planning. To obtain those resources, she would need to conduct a clinical trial to test whether her anecdotal impressions were empirically accurate.
Training Provides Catalyst for Health Care Innovation
In 2017, Dr. Carter received two awards with the support of Mass General’s Division of General Internal Medicine — a $300,000 grant from the Partners Center for Population Health and a year-long fellowship to Mass General’s Healthcare Transformation Lab (HTL).
The Healthcare Transformation Lab makes it possible for physicians to develop creative solutions to health care challenges. During the HTL fellowship, Dr. Carter designed a randomized control trial with her DGIM research mentors to test her theory and acquired the leadership and innovation skills she needed to win approval from hospital leadership for a permanent program. The result was the launch of the Clinical Care Transitions (C-CAT) Initiative, which has served more than 650 patients since its inception in 2017.
By providing support, health monitoring and patient advocacy, the program reduces readmissions and thereby lowers health care spending.
HTL Training Propels National Funding
At the same time, Dr. Carter was approaching what she called the “grant funding cliff” — the point at which pervious research funding runs dry. That’s when she hit the jackpot.
In 2020, she won a 5-year, $1 million K23 award from the National Institutes of Health (NIH) that will fund a second clinical trial to assess the effectiveness of community health workers in reducing readmissions among heart patients.
“My time at HTL supercharged me. It provided the expertise I needed to operationalize this effort and further my growth as an innovator and independent researcher.”
“This never would have happened without the support provided by HTL,” says Dr. Carter. “Getting the K23 grant was dependent on having sound preliminary data. Having already led a randomized control trial showed the funders that I’d already done the type of work they want to support.”
Dr. Carter will also use the NIH grant to study a smartphone app to monitor critical health indicators such as heart rate, blood pressure, oxygen levels and steps per day. It will include educational videos and an artificial intelligence component that flags warning signs of decline and can alert the patient’s community health team. A color-coded dashboard will provide health status at a glance so that the team can quickly determine which patients need clinical attention.
“My time at HTL supercharged me,” says Dr. Carter. “It provided the expertise I needed to operationalize this effort and further my growth as an innovator and independent researcher.”
To reduce hospital readmissions, Jocelyn Carter, MD, MPH, believed that the solution involved pairing at-risk patients with community health workers for 30 days.