Providence, R.I.-based Care New England has prevented emergency department visits and inpatient stays with its Integra Community Care Network.
The network, which launched in 2014, is the system’s accountable care organization that partners with the hospitals, nursing home and visiting nurse association. It forms “a tight continuum, where you can do more careful care coordination — where primary care doctors can talk to a centralized ACO team, and the ACO can follow patients into hospitals and then follow them home,” Ana Tuya Fulton, MD, president and COO of Integra and chief population health officer of Care New England, told Becker’s. “Integra’s goal is to fill the gaps between silos — to add other layers…and create a continuum.”
Integra interrupts the typical pathway — hospital admission transfer to a SNF or rehab then to home — and moves care further upstream to catch care needs before it requires hospital care. Its prevention and care services focus on older adults and those with multiple complex or chronic conditions, and are provided by an interdisciplinary team that includes hospital staff, primary care physicians, nurses, pharmacists, social workers and community health workers.
“We pride ourselves on reducing unnecessary care — if we can prevent a hospitalization by treating someone in their physician’s office or at home, that’s a success story for us,” Dr. Fulton said. “For older adults particularly, that means they won’t get deconditioned. They won’t end up in a nursing home for two weeks. They’ll be able to get care at home and stay there.”
Integra has roughly 80,000 members under population health management. In 2026, 16,489 patients have been enrolled or touched by the program so far. Integra at Home, its most intensive program, added 297 new members this year, bringing the total patients at home up to approximately 700.
On the hospital side, Integra has prevented 182 emergency department episodes and 60 inpatient stays. Those patients were able to receive early intervention and treatment at home.
Patient satisfaction surveys show more than 90% would “likely recommend” the program. Caregivers and primary care physicians have reported loving the program too, Dr. Fulton said.
With so much success, the network is looking to fine-tune services, demonstrate savings to the health system and CMS, as well as prepare the network for future growth.
“What’s been successful for us is reminding ourselves that our overarching goal, as an accountable care network forming this continuum of programs, is to solve a problem that has always existed in healthcare: it’s very siloed,” Dr. Fulton said. “Our goal has been to break down those silos and build bridges between the different parts of the health system.”
