Tags: coordinated care

Population Health Management patient Shirley Hutchins with a Partners at Home occupational therapist

It was late spring of this year when Shirley Hutchins's chronic breathing problems suddenly got worse. She had been diagnosed with pulmonary hypertension, or high blood pressure in the lungs, and pulmonary fibrosis, a kind of scarring on her lung tissue.

But even after using oxygen on a part-time basis for nearly a year, she couldn’t catch her breath. Walking up and down the stairs to her second-floor apartment in an East Boston triple-decker was all but impossible.

Mrs. Hutchins, 75, called her primary care physician, who told her to immediately check herself into Massachusetts General Hospital. She spent six days in the hospital, followed by a week in Spaulding North Shore, a rehabilitation hospital in the Partners HealthCare network.

But now that Mrs. Hutchins is out of the hospital, she still needs help. She must adapt to being tethered full-time to an oxygen tank. She has to build up her lung capacity so she can perform daily chores without becoming winded. And she must re-learn how to function in the modest apartment she has lived in for 35 years.

But, she is not alone. Twice a week, an occupational therapist from Partners HealthCare at Home visits Mrs. Hutchins.

On any given day, Partners HealthCare at Home treats about 4,000 people in eastern Massachusetts, stretching from Newburyport on the North Shore to Plymouth in the south. It is also an integral part of Partners’ efforts to improve patient care and health outcomes using population health management (PHM) – an array of cutting-edge care delivery strategies that is now helping more than 500,000 patients across Massachusetts.

On a recent morning, Anke Schafer guided Mrs. Hutchins through a series of exercises intended to increase the volume of air – and oxygen – she takes in with a single inhalation. She guided Hutchins as she stretched a giant rubber band in front of her chest at different angles, ten repetitions each time.

Population health management patient Shirley Hutchins exercising with Partners at Home occupational therapist

“I designed a program for Shirley to build up her accessory breathing muscles and open up her thoracic cavity,” says Schafer. Before starting, they checked a small finger monitor that measures the level of oxygen in Mrs. Hutchins’ blood.

“For Shirley, a good starting number is 95 before she begins her exercises. Where are you at now? You’re at 96. Hooray! That’s a good starting off place.”

As she went through her repetitions, Hutchins’ oxygen saturation level actually increased. “That’s because the volume of air she takes in with each inhalation is actually increasing,” explained Schafer. “Let’s do one more set and then rest. How are you doing?”

“I’m doing fine,” said Mrs. Hutchins. “I’m ready whenever you are.”

Critics of the U.S. healthcare system say that it is too fragmented, with critically ill patients handed off between hospitals and specialists with little coordination. The problem has been exacerbated by the traditional “fee-for-service” payment system, in which physicians and hospitals did not receive a payment unless they performed a billable service.

Partners HealthCare at Home is part of the solution, filling in the gaps in care that can occur when patients leave the hospital. Population Health Management techniques have helped Partners to keep patients like Shirley Hutchins out of the hospital for longer periods, and enabled them to become more involved in their own care. In addition to occupational therapists like Schafer, it deploys nurses, physical therapists, speech therapists, nutritionists, social workers and home health aides. The end result is lower healthcare costs and better health outcomes.

Reynold G. Spadoni, president of Partners HealthCare at Home, said home care is part of the “horizontal thinking” in which all parts of the healthcare system collaborate to do what is best for the patient. There is more focus on providing seamless, coordinated care, and less emphasis on which parts of the system are being compensated for providing services.

For Mrs. Hutchins, there are numerous benefits to home-based care. She is planning to get a portable oxygen tank, which will enable her to leave the house and visit with friends, and she has started to do chores like washing dishes and making the bed.

“Do you feel like you’re getting stronger?” asks Schafer, as she completes the exercise regimen.

“I do,” said Mrs. Hutchins. “I do my exercises in the morning and at night.”

Schafer gives her patient flying colors.

“From a perspective of being involved in her own care, she’s an A plus,” said Schafer. “She is totally involved and totally committed to her own recovery.”

Read more about how population health management is making a difference for Partners’ patients.