Care coordination network enables Aspire Health to best deploy case managers

By | May 16, 2019

Aspire Health Alliance in Quincy, Massachusetts, partners with healthcare organizations and clinics throughout Boston, the South Shore and the southeastern part of the state to care for patients struggling with behavioral health challenges.


Aspire Health Alliance has partnered with Spectrum Health Systems to form the South Shore Community Partnership, which uses health IT to successfully implement their Behavioral Health Community Partner program.

The BHCP program assigns patients with behavioral, mental, substance use or other health concerns to a dedicated case manager who is responsible for finding the patient and connecting him or her to medical and behavioral healthcare along with resources in the community.

When these patients include homeless or other transient populations, it makes tracking down patients difficult as phone numbers and addresses change frequently, if they exist at all.

“We needed a way to find these patients and connect them with the healthcare resources they need,” said Deborah Jean Parsons, director of integrated care at Aspire Health Alliance.

“In addition, because we participate in our state’s Medicaid system, MassHealth, we were under pressure to not only improve our patient outcomes but reduce our costs as part of MassHealth’s initiatives to streamline patient care,” she said.


To help its case managers track down patients, Aspire started working with Collective Medical, a national network for care coordination. Collective provides a lightweight platform that houses, interprets and sends patient data to help healthcare organizations using real-time patient notifications. These notifications alert providers like Aspire when one of its patients presents at a hospital.

“Because many of our patients are hard to reach, engaging with them while they are in the emergency department is one of the few ways that we can connect with them,” Parsons explained. “The plan was for us to start getting these real-time alerts so that our case managers would be able to connect with hard-to-reach patients while the patient was still in the hospital.”

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There is a variety of care coordination health IT vendors on the market today, including Ensocare, eQHealth, Greenway Health, GSI Health, Imprivata, Optum, pMD and VitalHealth Software.


Aspire uses Collective’s real-time notifications to receive alerts whenever one of its patients presents in a hospital. Case managers then can use those alerts to reach out to the patient and schedule a follow-up appointment.

The real-time notifications are especially helpful when trying to locate transient and homeless patients. When case managers receive an alert for one of these patients, they call the hospital and coordinate a time to visit while the patient is still in the emergency department.

“When the care coordinator received the alert that this patient was in the hospital, she was able to immediately go visit the hospital, sit down together with the hospital social worker and patient, and discuss resources for help.”

Deborah Jean Parsons, Aspire Health Alliance

By being able to follow-up with these patients immediately, before they are discharged home, case managers have been able to engage patients in their crisis state and find a higher rate of engagement, said Parsons.

“In one specific example, one of our patients showed up to the South Shore Hospital inebriated, and Collective sent us a notification,” she said.

“Before this, the patient’s care coordinator at Aspire had been unsuccessful at reaching the patient by phone or e-mail,” she explained. “When the care coordinator received the alert that this patient was in the hospital, she was able to immediately go visit the hospital, sit down together with the hospital social worker and patient, and discuss resources for help.”

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Together, they worked out a plan for him, signed him up for the Behavioral Health Community Partner program, and got him an appointment with a Medication Assisted Treatment facility the next day, she added.


The real-time notifications have allowed Aspire case managers to follow-up with more patients during their hospital stay and engage members. When a patient is in the hospital, they are more likely to want Aspire services and Aspire has found that when it reaches out to members in the hospital, it has a 50 percent engagement rate.

“When our staff members can’t connect with a patient during their hospital visit, the notifications are still helpful in coordinating care,” Parsons said. “By knowing that the patient was in the hospital, we can follow-up accordingly with other communication methods and work to connect the patient with a doctor or social worker who will get him or her the care they need, without having to go to the emergency department.”

Another benefit of the care coordination network is the history of the patient over the past year; further, the contact information in their system is more accurate than what Aspire gets from MassHealth or its healthcare partners, Parsons added. Having up-to-date contact information on patients also has helped Aspire find and engage more patients, she said.


“Regardless of a homeless or transient patient population, real-time alerts like these help you find, engage and follow-up with all of your patients,” Parsons advised. “Once you find them in the hospital, you can make sure that they get the resources and programs they need as soon as possible. When you do this, patients not only sign up for your services, they are grateful for the help.”

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Another huge piece of the puzzle is getting buy-in from the hospitals and patients. For this system to work, everyone involved needed to be receptive to working collaboratively, both within and outside of the Collective platform, she added.

“Something that’s really helped us to get everybody on board is having good, positive examples of how the real-time notifications work so that hospitals can see the value of utilizing the platform,” said Parsons. “This is especially important for vulnerable patients, since many of these patients have tried similar programs that have not worked for them in the past and are therefore distrustful of any new service.”

Being able to help them in real time when they are in crisis is the best way Aspire can engage patients, she added, noting that the care coordination network is proving to be one of the best tools for helping Aspire patients get the care they need in real time.

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