Boston Medical Center Health System (BMCHS), a leading safety net organization, delivers high-quality care to Medicaid and underserved populations through an innovative and multidisciplinary population health team. To strengthen outcomes for affiliated accountable care organizations, the team launched a centralized outreach program designed to close persistent gaps in behavioral health, perinatal care and chronic disease management. This model replaces fragmented, clinic-based workflows with timely, clinician-supported outreach that meets patients where they are, reduces barriers to care and improves performance on key MassHealth quality measures.

Through initiatives such as the Follow-Up After Hospitalization for Mental Illness (FUH) program, trained behavioral health clinicians connect with patients immediately after discharge, providing real-time support, care coordination and clinical assessment to enhance continuity and safety. Similarly, the  postpartum outreach program offers flexible telemedicine visits to help new parents overcome challenges and ensure timely, comprehensive postpartum care. Complementing these efforts, COACH-BP is a hypertension telephonic follow-up program that empowers patients through education, home monitoring support and rapid access to care teams. Collectively, these centralized clinical outreach strategies elevate the patient experience, improve health outcomes and strengthen our ability to achieve strong accountable care organization quality performance, thereby sustaining BMCHS’s critical safety net mission.

Learning Objectives:

• Explain how the population health team partners with accountable care organizations to improve quality, equity, and care delivery for Medicaid patients.
• Analyze common gaps in behavioral health, perinatal care and chronic disease management and evaluate how centralized outreach strategies can address these barriers.
• Apply lessons from the Follow-Up After Hospitalization for Mental Health, postpartum and hypertension centralized outreach programs to provide effective and timely patient care.
• Utilize the Population Health Playbook to replicate or adapt centralized outreach programs to other organizations.