High utilizers of acute care in nonurban settings are at risk for poor health outcomes. Much of Massachusetts is nonurban, with many residents experiencing limited access to health care providers, fragmented health care services, inadequate housing, and low health literacy. This study examines patient perspectives on the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program, a state-based grant program focused on advancing community hospitals toward value-based care. We found that CHART staff engaged patients in care coordination and patient advocacy, promoted patient agency and health literacy, and provided socioemotional support. These findings may help inform future program development around meeting the medical and social needs of high utilizers of health care services.
Keyphrases
- healthcare
- quality improvement
- end stage renal disease
- acute care
- mental health
- case report
- newly diagnosed
- ejection fraction
- health information
- chronic kidney disease
- peritoneal dialysis
- prognostic factors
- primary care
- palliative care
- affordable care act
- patient reported outcomes
- patient reported
- electronic health record
- mental illness
- pain management