Even before the pandemic inundated our communities with health care challenges, local providers, hospital systems, health plans and community organizations had been working together to identify what resources New Englanders needed most to live healthier lives.

There are many barriers to care that are unique to New Englanders. To help identify and address those barriers, Harvard Pilgrim Health Care created a Quality Grant Program that supports the work of those who are traditionally closest to the patients themselves—health care providers.

Established 22 years ago, Harvard Pilgrim Health Care’s Quality Grant Program has provided over $21 million to support providers who are improving care delivery and access across New England.

We caught up with two of the 2020 grant recipients, Lowell General Hospital and MaineGeneral Medical Center, to see how their programs progressed over the last year and a half. Their out-of-the-box solutions to addressing social determinants of health, like transportation access and food insecurity, go beyond the standard approach. Not to mention, their programs have become a soundboard for the community to voice their greatest challenges and feel heard.

Here’s how it all began, and where they are now:

Community health system delivers health care on wheels

In a 2019 study conducted in Lowell, Massachusetts and its surrounding areas, 33% of respondents reported the most frequent barrier to care was lack of transportation to a medical facility.

The connection between transportation barriers and missed or delayed health care can often result in poorer health outcomes. For those who are managing a chronic disease, it can even be the reason for worsened conditions or hospitalization.

To conquer these challenges, lessen emergency room visits and ease the burden of getting to a facility, Lowell General saw an opportunity to bring care directly to patients.

Before the pandemic, Lowell General was planning to launch a Mobile Integrated Health (MIH) program, built to visit patients at home who were discharged from the hospital with risk of readmission. The goal was to provide streamlined patient care to improve their experience and prevent unnecessary readmissions. In March 2020, launching the program skyrocketed up the priority list to assist with the community pandemic response.

For distressed patients facing the closure of medical clinics and interrupted public transportation services, a visit to the ER for non-COVID medical issues was not a consideration. According to the CDC, an estimated 41% of U.S. adults reported having delayed or avoided medical care during the pandemic because of COVID-19 concerns.

Barbara Vaillant, lead paramedic for Lowell General Hospital’s Mobile Integrated Health program, sits in the program’s new vehicle.

Lowell General saw an immediate need in the community and quickly expanded their program to take any referral that came in, helping patients continue to receive the care they needed, including emergency services and COVID-19 vaccinations for those who were homebound.

The community hospital began providing at-home care visits to individuals across Lowell and the surrounding areas. They fast-tracked obtaining their state license to provide paramedic care to visit homes in the community, knowing there was an immediate need to get on the ground and running.

They even transformed a van into a mobile health clinic, equipped to provide vital assessments, physical exams, phlebotomy, ECGs, IV fluids and select medications; they also helped facilitate telehealth appointments with physicians. As the program evolved, the focus became visits that prevented avoidable trips to the ER or inpatient admissions.

Lowell General Hospital’s Mobile Integrated Health team includes, front row, from left, Alicia Krysiak, navigator; Katie Matte, PHO program director for population health; Wendy Mitchell, MD, Lowell General MIH Medical Director; Jonathan Drake, MD, Lowell General Chief of Emergency Medicine; and Barbara Vaillant, lead paramedic; and back row, from left, Dan Cardona, paramedic; Casey Rainville, Lowell General Director of ALS; Ian Cissel, paramedic; and Chris Vozzella, paramedic.

With the assistance of Mobile Integrated Health, one patient struggling with alcoholism and who suffered from severe heart and lung conditions, on top of several recent hospital admissions, was able to stay out of the hospital for six months. The paramedics found that the patient was living at home with little to no income and without a support system. They were quickly able to provide the appropriate medication, dietary counseling, chronic disease education and intravenous diuretics needed. After one month, the patient was 30 days sober, eating low-salt foods, had all the correct medicine in place and was feeling significantly better.

“Our health care system has become increasingly more difficult to navigate over the years, especially for the medically complex and those facing social determinants of health. Mobile Integrated Health provides a solution for treating these patients in their homes and provides continuity of care in a health care system that has become increasingly episodic.”
— Dr. Wendy Mitchell, Medical Director, Lowell General Hospital

Since the inception of the program in late March of 2020, Lowell General has successfully delivered 1,514 at-home visits, by which an estimated 660 emergency room visits and 301 admissions have been avoided. But the program’s success reaches far beyond the logistical feat accomplished by the partnership of facilities, providers and some innovative thinking; it’s made a difference for real people in need. In fact, their repeat patients have cited the power of the program to help them stay out of the hospital and improve their health despite transportation barriers.

Screening for hunger in rural Maine

13.6% of Maine households are food insecure, the highest rate in the New England region. Across the U.S., many of the individuals who were already facing these food challenges have faced greater hardship since COVID-19.

Many Mainers living in rural areas said they would need to drive over 30 miles to access the nearest food source.

Maine faced a high need for new innovations to increase access to healthy food. In 2020, MaineGeneral expanded the use of its Hunger Vital Signs screening tool so that providers at four Kennebec Region Health Alliance practices had a simple and effective solution for identifying patients with food insecurity.

Over the last year and a half, the tool has been used to screen close to 5,000 patients, with almost 600 of those patients screening positive for hunger. But the tool’s effectiveness expands beyond pure screening; it’s given providers a new way to empower and support patients to seek help. Nearly 76% of patients who screened as food insecure followed up, with many receiving emergency food bags and food resource guides to help them learn about access to additional food resources. This is especially critical during the winter months when food insecurity is most challenging. The assessment has given providers, health organizations and food banks in the surrounding areas the insight and ability to be more proactively prepared with resources and awareness-building initiatives during this time.

“This program has helped me be a stronger advocate, see more of what we as a health center can do better to assist our patients, and understand what their specific needs are.”
— Chenoa Jackson, LSW, HealthReach Care Connector, Madison Health Center and Lovejoy Health Center in Albion, ME

Throughout the program, MaineGeneral assessed individuals for other social needs, like those experiencing the impact of the housing shortage, particularly in low-income areas. Individuals who voiced their concerns were quickly connected with the local housing authority for further assistance. Without this bridge to critical services and support, patients would have been left further isolated in the challenges that impact not just their finances, but their health.

The reach of the program has had a cascading effect and has helped participants to feel more secure in allocating their monetary resources to their health needs, such as medications and regular doctor visits, rather than stretching their wallet to pay for food.

“Our families are so grateful for the food bags. They have often returned to our office asking for another. It is hard for us to imagine that we have so many families struggling to get food on the table.”
— Jan Bureau, Practice Administrator, Waterville Family Practice

Finding solutions takes collaboration

Since its inception, Harvard Pilgrim Health Care’s Quality Grant Program has supported over 300 unique projects that have helped support better health across New England. Each project has its own distinct challenges, like transportation, language, housing and food needs. Through proactive collaboration between the payer and provider roles in the system, gaps in patient care can be minimized, and new and innovative solutions can help local communities achieve better health.

Harvard Pilgrim Health Care and Tufts Health Plan, as part of Point32Health, are pleased to announce that the Quality Grant Program will continue to be offered in 2022 and beyond for providers in both Harvard Pilgrim Health Care and Tufts Health Plan networks.

If you are a provider interested in learning more about the Quality Grant Program, Harvard Pilgrim’s site.