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Massachusetts Health Policy Commission
April 2019
This month’s newsletter focuses on health-related social needs, and highlights Behavioral Health Network’s housing security initiative and Boston Medical Center’s care coordination initiative for patients with social and legal needs. We are also excited to announce the launch of the SHIFT-Care Track 1 programs addressing health-related social needs.
Let us know if there are particular care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. We'd love to hear from you! Email us at caredeliverytransformation@mass.gov .  
Team HPC
HPC SHIFT-Care Award Recipients Launch Health-Related Social Needs Programs
In the coming weeks, 15 health systems across the Commonwealth that received funding through the HPC’s latest investment program, the SHIFT-Care Challenge, are launching innovative new initiatives. Five of these initiatives are focused specifically on addressing certain health-related social needs (HRSN) in order to decrease patient use of costly and avoidable hospital care. The SHIFT-Care awardees and their HRSNs of focus are:
  • Community Care Cooperative: economic stability, food access, access to vocational opportunities, community and social connectedness, housing, and access to social services
  • Boston Medical Center: housing, food security, employment, transportation access
  • Hebrew Senior Life: nutrition services, social engagement
  • Baystate Health Care Alliance: asthma control and asthma triggers related to home environment
  • Steward Health Care Network: housing, employment, transportation access, food access, health care access
Prior to launch, awardees have been engaged in preparation activities such as hiring and training frontline staff, developing marketing and communication materials for internal and external stakeholders, preparing operational processes and protocols, and developing information technology capabilities to track outcomes. In collaboration with the HPC, awardees are creating measurement templates to capture key performance indicators on services delivered and patient outcomes throughout the 18-month program implementation period. 
The HPC congratulates all of the SHIFT-Care awardees as they launch their initiatives, and looks forward to sharing more information about their progress over time. Check back in with the Transforming Care Newsletter for highlights and lessons learned over time.
Behavioral Health Network Program Addresses Patients’ Housing Insecurity 
As an awardee of the HPC’s Health Care Innovation Investments (HCII), Behavioral Health Network, Inc. (BHN) developed a care model to serve patients and families with behavioral health needs who are homeless or at risk of homelessness. The Families in Transition Project (“Project FIT”) provided whole-person and whole-family care coordination with the ultimate goal of ensuring a stable and successful housing placement. Multidisciplinary care teams working with the families enrolled in Project FIT also helped connect families to behavioral health care, primary care, social services, and vocational services. 
Like many other HCII awardees innovating to address HRSN, BHN encountered challenges measuring its initiative's progress. Despite anecdotal successes in ‘moving the needle’ on housing security for many of their enrolled families, the team found it difficult to capture their efforts quantitatively. BHN first tried to measure impact by counting the number of families who became permanently housed, but that simple measure failed to capture more incremental steps toward stable housing that enrolled families were experiencing. 
In collaboration with the HPC’s Strategic Investments evaluation team, BHN decided to apply the housing domain ratings of the Arizona Self-Sufficiency Matrix to its data as a means of capturing the right level of sensitivity to demonstrate the impact—and value—of its program. The tool allows for ranking a patient’s status on a scale of 1-5 across domains of housing, employment, food, child care, income, and other social factors. 
After applying this tool to their housing status data, BHN’s Project FIT team was better able to illustrate its success in improving patient housing status. The team determined that the program more than doubled the percentage of families safely housed and tripled the percentage of families with permanent housing.
BHN’s experience helps demonstrate how important it is for measurement tools and methods to continue evolving so that innovators can evaluate their efforts to address patient needs beyond the traditional boundaries of health care.
Boston Medical Center Initiative Assists Patient Social and Legal Needs
Through their HCII award from the HPC, Boston Medical Center (BMC) developed the High Touch, High Trust (HT2) initiative to provide care coordination and patient navigation services in BMC’s emergency department (ED). Patients are identified for the HT2 program through their utilization history and are enrolled in the program by research assistants, who are flagged when the patient presents in the ED. The HT2 initiative deploys community health advocates trained by civil legal aides from the Medical Legal Partnership of Boston (MLPB). These community health advocates assess and partner with patients inside and outside of the hospital to identify, prioritize, and address their health-related social and legal needs, including utility shut-offs, evictions, domestic violence, benefits assistance, and immigration concerns. 
The members of the interdisciplinary HT2 team meet weekly to discuss the needs and care goals of each HT2 enrollee. One HT2 patient had screened positive for unmet HRSN because both he and his spouse had mobility limitations that were making climbing the stairs to their apartment increasingly uncomfortable and dangerous. Despite providing verification letters in support of getting 1 st floor housing to accommodate their health needs, the HT2 participant received no response or action from building management.
After working with a community health advocate, the patient, empowered by HT2’s support and his knowledge of his rights, contacted a VP-level leader at the building’s management company, and has since been approved for a transfer to a 1 st floor apartment.
HPC to Release Insulin Spending DataPoints 
Growth in prescription drug spending has outpaced most other categories of spending growth in Massachusetts in recent years, and individuals with chronic conditions face an increasing financial burden to manage their conditions. Spending for insulin and other health care services for Massachusetts individuals with diabetes specifically have grown considerably over the past few years, according to a new analysis by the HPC. The HPC found that average annual spending on healthcare for this population increased by 31 percent between 2013 and 2016 (from $13,045 per person in 2013 to $17,061 in 2016). Specifically, average annual spending on insulin alone increased by 50 percent (from $3,122 in 2013 to $4,684 in 2016), accounting for 39 percent of the total spending increase.
More information about insulin spending will be highlighted in the 11 th issue of the HPC’s DataPoints Series , a collection of online briefs that highlight new research and findings relevant to the HPC’s mission to drive down the cost of healthcare. In this issue, the HPC analyzes spending trends for commercially-insured patients living in the Commonwealth who have diabetes and use insulin to manage their condition. 
Coming Soon—HCII Program Profiles
In the coming weeks, the HPC will publish profiles of the 20 HCII awardee initiatives, targeting some of the Commonwealth’s most persistent health care cost challenges with innovative partnerships, technology, and protocols. The profiles highlight key features of these initiatives, including their care models, program aims and target populations, and partnerships with other organizations.
The HCII program represents over $11 million of public investment in innovative projects that further the HPC’s goal of better health and better care at a lower cost. The program includes three funding pathways focusing on:
  • Innovative delivery and payment models to reduce healthcare costs
  • Care for mothers and babies impacted by neonatal abstinence syndrome
  • Implementation of telemedicine programs for increased behavioral health care access
The HPC looks forward to sharing results and learnings from each of the three pathways of the HCII Program over the coming year. 
Massachusetts Behavioral Health Partnership Launches the Massachusetts Consultation Service for the Treatment of Addiction and Pain 
Massachusetts Consultation Service for the Treatment of Addiction and Pain (MCSTAP) is staffed by a team of physicians providing real-time telephonic consultation to primary care providers (PCP) on safe prescribing and care management for adult patients with chronic pain and/or substance use disorder. MCSTAP also provides resource information on community-based programs to support this population. MCSTAP’s services are free of charge and available to support PCPs caring for all Massachusetts adults regardless of insurance coverage. To reach MCSTAP, call 1-833-PAIN-SUD (1-833-724-6783), Monday through Friday, 9:00 a.m. to 5:00 p.m. The program is funded by the Massachusetts Executive Office of Health and Human Services. More information about MCSTAP is at www.mcstap.com .
Health Policy Commission
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