Speare Memorial Hospital: Cultivating New Partnerships for Improved Care Coordination

Speare Memorial Hospital, a critical access hospital located in Plymouth, New Hampshire, was one of six organizations selected to participate in the 2022-2023 Rural Health Provider Transition Project (RHPTP).

During its year-long engagement in RHPTP, Speare Memorial Hospital (SMH) worked with RHPTP’s technical assistance (TA) consultants on finance and operational improvements, as well as developing a strategy and infrastructure to improve care coordination in preparation for participation in an alternative payment and care delivery model. 

This project has helped us decrease the average length of stay, and has tremendously improved teamwork and collaboration, as everyone is recognized as having a role in the coordination of care.

Michelle McEwen, President & CEO, Speare Memorial Hospital  

Below are some of the hospital’s top accomplishments and early outcomes made possible through their RHPTP participation.

Top Accomplishments:

• Reduced readmission rates 
• Developed a process map flow for care transitions
• Decreased average length of stay
• Improved communication via monthly readmission meetings and interdisciplinary rounding
• Increased collaboration and discharge planning with home care agencies
• Added early education and assistance with long-term Medicaid applications for eligible patients
• Implemented patient assessments upon admission regarding potential home-life needs and challenges 
• Partnered with Transport Central to focus on improving patient discharge transportation
• Implemented real-time and continual notification to primary care providers when patients return to the emergency department
• Initiated the inclusion of caregivers, partners and significant others in patient discharge plans and resource identification

SMH has seen RHPTP’s impact particularly related to their improved organizational culture and overall patient experience. 

And that is just the beginning. In order to integrate strategy and a strong infrastructure to improve their coordination of care, SMH needed to define the care coordinator role in both the inpatient and outpatient settings as well as how this role would interact with other departments or programs. The team performed a tracking exercise for care coordinator tasks to identify gaps and where clarification of responsibilities and additional resources were needed. They also clearly defined the care coordination roles and duties with respect to community partners, referrals and shared communication. In addition, process flow mapping was completed to improve coordination of care post-discharge. This was a significant area of improvement and development for SMH with the organization noting increased relationship building and communication between providers, case managers, patients and insurance providers. Supporting this effort has resulted in the ability to share health care data quickly, often in real-time, with primary care providers. 

In the coming months, SMH plans to continue the push toward improved processes and efficiencies in the areas of finance, operations, quality, population health, data analytics and rural health access, to name a few. Education and partnerships also remain top of mind with plans to collaborate with several external organizations, as well as internal departments and leaders with the goal of improving training and annual competency measures. Additionally, hospital leaders continue to work closely with its human resources and nursing education departments to create an evidence-based leadership program focused on driving effective change. The SMH team noted that while the tools they acquired from the RHPTP quality improvement TA consultants (Stratis Health) and financial and operational TA consultants (Stroudwater Associates) will take time to digest and implement, they have a solid foundation to continue building current and future initiatives. 

Speare Memorial Hospital is a wonderful example of a health care organization utilizing existing resources to bolster their many strengths and recent goals. The RHPTP team is excited to see what this transition to value-based care brings to their community and is so fortunate to celebrate their progress and commitment in the project.