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Enabling Accountable Community Care in Western Massachusetts

members of the community stacking their hands, one on top of another, to signify teamwork

In western Massachusetts our community has come together to form the BeHealthy Partnership, a collaboration of health care and human services entities focused on enhancing the health and wellness of our residents. One key program is focused on Medicaid recipients.

In March of 2018, we received a file of 40,000 MassHealth Medicaid recipients who have been attributed to our new Accountable Care Organization, along with a 200-page contract committing us to report needs assessment data, care management activities, clinical quality, patient satisfaction, turnaround times, and much more to The Executive Office of Health and Human Services (EOHHS) over the five year Delivery System Reform Incentive Payment (DSRIP) program. They will know the total cost of care for our members and determine if our efforts result in healthier individuals and a lower total cost. If we prove that, we’ll have a sustainable business for many years to come. If not, our future is in jeopardy. Bottom line, we must make this work.

The MassHealth Program

MassHealth’s DSRIP waiver authorizes $1.8 billion over five years to support the restructuring of MassHealth’s delivery system to promote integrated, coordinated care and hold providers accountable for the quality and total cost of care. The program contracts with 17 Accountable Care Organizations (ACOs) and 26 Community Partners to integrate primary and specialty care, behavioral health, long term services and supports (LTSS), and health-related social services.

Our BeHealthy Partnership includes Health New England—the prime contractor—and Baystate Health, the largest integrated health care system in western Massachusetts, with five hospitals, more than 80 medical practices, home care and hospice services. Caring Health is our Federally Qualified Health Center partner. Long Term Services and Supports (LTSS) and Behavioral Health care management services are provided by a dozen individual Community Partners. All these entities have come together to share processes and data to serve the residents of western Massachusetts.

Enabling Community Based Care Management with HealthShare

The members of our BeHealthy Partnership each use different patient management and EHR systems. So how are we tackling the challenges of community-wide consent, care management, data sharing, and system interoperability? Using InterSystems technology, the foundation of our trusted Pioneer Valley Information Exchange (PVIX), and with the help of our integration team from SMC Partners, we are building shared services for BeHealthy partners to collaborate in performing:

  • Eligibility Management and provider attribution
  • Care Needs Screening for each member, performed by care teams and Community Health Workers
  • Comprehensive Needs Assessment
  • Referrals to Community Partners
  • Care Planning
  • Activity and Service Tracking
  • Outcomes Measurement
  • Consent Management controlled by our patients

We are aggregating patient data from disparate systems so that providers can see the whole picture of their patients, with a couple clicks from within their own EHR systems. Patients themselves can view their health history, medications, lab results and radiology images, all online via our secure patient portal. Secure text messages connect patients and their caregivers. And our program administrators have the data they need to show results and prove value.

Our vision is true community-based, collaborative care, with patients and their families in the center and in charge. We intend to prove that better care and outcomes really can cost less.

Read the latest blog posts on InterSystems PULSE.

About the Author:

Ken Riley is the Director, Patient and Population Health Technologies, Baystate Health and the Director of the Pioneer Valley Information Exchange (PVIX), built on the HealthShare platform.

Connect with Ken Riley on LinkedIn.

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