Health care reform and the adoption of the 2010 Affordable Care Act created a new health care objective: To improve the quality of patient care and satisfaction while reducing costs. This reform provided Springwell with the opportunity to play a crucial role in helping health providers reach that goal.

Accountable Care Organizations (ACOs), developed by the Centers for Medicare and Medicaid, are judged by their ability to reduce the rate of rehospitalizations,” explains Jo White, Springwell’s Health Care Partnership Manager. “They’re encouraged to work with community-based organizations like Springwell to ensure their patients have the community long-term care services they need.”

In collaboration with area hospitals, physician groups and ACOs, Springwell works to meet the needs of patients returning from a hospital stay or who are at risk of hospitalization. Springwell’s Community Care Coordinators ensure access to in-home services crucial to successful recovery at home: delivery of nutritious meals, transportation to medical appointments, help with dressing, housekeeping, and laundry and information about local private and public resources.

For the past year, Springwell has engaged in four pilot partnerships with area hospitals and physician groups. Working closely with social workers and discharge planners at Mount Auburn and Beth Israel Deaconess/ Needham, Springwell helps coordinate patient-specific services. A dedicated Springwell staff liaison collaborates with social workers at Harvard Vanguard Medical Associates’ Watertown and Wellesley sites to facilitate communication and coordination. In addition, a Springwell staff member works onsite at the Beth Israel Deaconess Care Organization, alongside RN Case Managers, providing referrals for community resources. Originally a temporary, part-time position, the arrangement has proved so successful that it has been expanded to a fulltime role.

Initial data shows that the pilot projects are working: Patients on the receiving end of the collaborations show a significantly lower readmission rate.

Hospitals and physicians are beginning to see us as a valued partner,” says White. “Communication between hospitals, ACOs and agencies like Springwell make all the difference to patients. Hopefully, the new model will mean greater success following discharge-and cost savings for everyone concerned.”