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Jocelyn Carter, MD, MPH, Internal Medicine Hospitalist and Clinician Scientist, Mass General Hospital (MGH). The C-CAT (Community CAre Transitions) initiative was structured as a randomized controlled trial in 2017-2019, focused on reducing readmissions prior to transitioning to being operationalized by MGH for internal medicine adult patients in 2019. The C-CAT initiative prioritizes best practice by focusing on patient-centered care. After meeting patients in-hospital prior to discharge, CHWs work actively for 30 days post-hospital discharge (via phone calls, home visits, accompaniment to clinic/intake appointments) to foster connections to clinical care teams, connect patients to low/no-cost resources (e.g. food, transportation, housing) and close resource/knowledge gaps contributing to sub-optimal care. CHWs create space for patients to voice barriers to staying well and work to bring greater awareness to all members of the inpatient/outpatient interdisciplinary care teams to improve care. Positive outcomes were generated from the C-CAT for 30-day readmission, emergency department visits and missed post-discharge appointments. Dr. Carter shares all implementation processes and outcomes.
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