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Massachusetts Health Policy Commission
February 2018
Thank you for your continued engagement in the HPC's care delivery transformation work. In this newsletter edition, we are pleased to announce a new free technical assistance opportunity for primary care practices, share best practices for caring for infants with neonatal abstinence syndrome from Lawrence General Hospital, convey a motivating patient success story from Boston Health Care for the Homeless Program, and let you know about recent accolades our provider partners have earned.
Please let us know if there are any other care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. You can also view last month's newsletter here . We love to hear from you! Please email us at HPC-CareDeliveryTransformation@massmail.state.ma.us .
Team HPC
NEW technical assistance program available to support behavioral health integration into primary care 
The HPC is pleased to announce the launch of a new technical assistance (TA) program to support primary care practices in developing behavioral health integration (BHI) capabilities and achieving PCMH PRIME Certification. The HPC has contracted with Health Management Associates to deliver the TA program, which includes individualized practice coaching, a series of behavioral health webinars, and in-person knowledge sharing sessions. ( Click here to view an infographic with key insights from our last knowledge sharing session on treating opioid use disorder in primary care).There is no fee to participate in PCMH PRIME TA.
Interested in integrating behavioral health at your primary care practice? Need technical assistance to meet your goals? Join us!
  • Primary care practices that commit to applying for PCMH PRIME Certification by getting on the Pathway to PCMH PRIME can APPLY NOW to receive up to 20 hours of expert practice coaching on BHI, at no fee. Practices wishing to participate in practice coaching during 2018 are encouraged to submit an application to the HPC by June 1, 2018. 
  • Practice coaching can support a BHI project of the practice’s choice on topics such as workflow design for BHI, financial management for BHI, or behavioral health telehealth program planning.
  • The PCMH PRIME TA program also offers a series of behavioral health webinars and in-person knowledge-sharing sessions that focus on operationalizing behavioral health capabilities in primary care.

To learn more about PCMH PRIME TA, visit the HPC website or contact HPC staff at HPC-Certification@MassMail.State.MA.US.
This month, representatives from Lawrence General Hospital presented results to date on their Neonatal Abstinence Syndrome (NAS) Investment program at the HPC’s Care Delivery Transformation committee meeting on February 14. The goal of the HPC’s NAS programs is to contribute to the Commonwealth’s efforts to address the opioid epidemic by supporting enhanced care and treatment for mothers and infants impacted by opioid use.
Lawrence General Hospital’s NAS intervention aims to achieve this through an integrated treatment model that includes enhanced training for inpatient clinicians on NAS assessment and treatment, and the expansion of a non-pharmacologic intervention known as “rooming-in,” a practice by which a private room is designated for the infant and the parent(s) in order to provide care. 

Dr. Dan Hale, MD, the Investment Director, and Ms. Heather Topp, LCSW, the Program Coordinator of the Lawrence General Hospital NAS program provided an overview of their first year of implementation and offered several positive early outcomes:
  • 30% decrease in the cost of care for infants with NAS between CY 2016 and CY 2017
  • 70% increase in the rate of breastfeeding for eligible maternal/infant dyads between CY 2016 and CY 2017
  • 57% decrease in the number of opioid-exposed infants requiring pharmacologic treatment for withdrawal between CY 2016 and CY 2017.

Factors that contributed to these outcomes include:
  • Training: All social workers, nurses and physicians are trained on NAS care guidelines, updated polices, and trauma-informed care. They created a video to share the goals of their program and the importance of their work.

  • Community outreach: Pamphlets and brochures describing the program were distributed to primary care providers and other community resources to raise awareness of these services and to promote care coordination prenatally and postpartum.
  • Non-pharmacologic treatment: The program emphasizes non-pharmacologic methods such as breast-feeding, skin-to-skin contact between mother and infant, quiet and calm environments, and soothing contact via volunteer “cuddlers.”

  • Program dashboard: Tracking program-specific metrics over time helped the team understand successful protocols and identify areas for improvement.

The HPC would like to thank Dr. Hale and Ms. Topp for presenting on their initiative, and congratulate them and the entire Lawrence General NAS team for their accomplishments and ongoing commitment to this work! 
Patient-centered coordination across settings
Boston Health Care for the Homeless Program (BHCHP), a Patient-Centered Medical Home (PCMH) PRIME-certified provider and an HPC investment awardee of the Targeted Cost Challenge Investment program, assures high-quality care for all homeless men, women, and children in the Greater Boston area. Through their HPC investment award, BHCHP provides cross-sector care coordination for their highest-cost patients with a diverse consortium of providers of primary and behavioral health care, housing, shelter, and other social services. BHCHP recently shared a patient story that demonstrates the importance of including the patient's voice during care coordination activities across providers and settings.

The patient, a homeless veteran, was admitted to BHCHP’s respite program for several months due to declining health. While he had recently been placed at a skilled nursing facility following a hospitalization, he felt the facility was too restrictive and left to stay at local shelters. The BHCHP initiative team learned that while he had been assigned a case manager at a consortium partner, New England Center for Homeless Veterans (NECHV), the patient had not been connected with services through Veterans Affairs. 

The BHCHP initiative team scheduled a case conference to discuss placement options, and included the patient, his primary care provider, his inpatient case manager, and his social determinants of health NECHV case manager. Importantly, the patient was present to provide real-time feedback and input to ensure the care plan fit his unique needs and preferences for care. As a result of the case conference, the team and patient agreed on an appropriate placement at a shelter. He was discharged from respite care and transferred to the shelter. 

The patient has reportedly settled into his new placement and is participating in a transitional housing program, working with a housing advocate in order to progress to independent housing. He will continue to work with his case manager to connect with additional services available to him through NECHV and Veterans Affairs.  
CHART Phase 2 Programs
As of February 1, 2018, the 24-month initial grant period of the Community Hospital, Acceleration, Revitalization, and Transformation (CHART) Phase 2 program is complete. Over five years ago, the HPC began planning the first phase of CHART, designed to build organizational capacity within eligible Massachusetts community hospitals for care delivery transformation. Many CHART Phase 1 pilots informed the framework for Phase 2 care delivery models.
September 2015 marked the rolling launch of CHART Phase 2 programs to reduce unnecessary hospital utilization, enhance care for patients with complex social, behavioral, and medical needs, and improve post-acute care in the community. Throughout the initiative, 27 community hospitals participating in 25 CHART programs employed over 250 full-time equivalents to serve thousands of patients across Massachusetts.
The HPC is incredibly proud of the accomplishments of CHART Phase 2 programs and their formidable efforts in transforming care delivery to meet the complex needs of vulnerable patients. As many CHART Phase 2 programs have been extended (via “no-cost extensions”) into 2018, we remain committed to supporting them through program end, and to partnering with them to further disseminate lessons learned. The HPC is developing an operational handbook with lessons learned and promising practices along with valuable tools and case studies from the experiences of CHART Phase 2 teams throughout the implementation of their care delivery redesign initiatives. An external evaluation of CHART Phase 2, conducted by the Boston University School of Public Health, is also in progress, with several reports expected to be published later this year and during 2019.
Stay tuned for more information, and join us in congratulating the tremendous work accomplished by CHART Phase 2 programs! 
Health Care Innovation Investment Program – Targeted Cost Challenge Investment (TCCI): Spaulding Hospital Cambridge
Last month, Ms. Holly Ellington and Mr. Patrick Hebble from Spaulding Hospital Cambridge’s TCCI initiative presented a poster on their program at the Commission for Case Manager Certification’s New World Symposium 2018 in Nashville, Tennessee. 
Known as the Post-Acute Care Transitions (PACT) team, Spaulding’s TCCI program aims to reduce the length of stay and readmission rate for the chronically, critically ill patient population at their long term acute care (LTAC) hospital. Patients enrolled in the program are assigned to a care transitions nurse who provides longitudinal case management and palliative care from LTAC admission until home for 30 consecutive days. Early results show a decrease in readmissions. 

As the program continues, the team will continue to focus on 1) completing MOLST (Medical Orders for Life Sustaining Treatment) forms for better patient education and quality of life, and 2) leveraging relationships with skilled nursing facilities for more effective placement and care transitions. Read the complete poster here.  
HPC SHIFT-Care grant opportunity: This $10 million grant opportunity is designed to foster innovative care delivery models in Massachusetts that shift the unnecessary delivery of care for complex patients from expensive, acute care hospitals, to more patient-centered, community-based settings.

The HPC recently updated its RFP and several related documents. Please see the SHIFT-Care webpage for the most recent versions. The deadline for eligible proposals is April 6, 2018 at 3pm EDT.

Health Leads is facilitating an interactive, 18-month learning program where care teams at hospitals and health centers across the country will learn effective strategies for strengthening and expanding their existing social health interventions. Applications are due March 22, 2018.

The Massachusetts eHealth Institute’s (MeHI) Learning Collaboratives provide a forum for stakeholders to discuss and address topics that challenge the healthcare community. The Spring workshops will focus on increasing health information exchange adoption through process improvement.
Blue Cross Blue Shield of MA Foundation
Blue Cross Blue Shield of MA Foundation
Agency for Healthcare Research and Quality

Institute for Healthcare Improvement

Institute for Healthcare Improvement

Rural Health Information Hub

Bureau of Substance Abuse Services
Massachusetts Department of Public Health

Massachusetts Association of Community Health Workers

Boston University School of Social Work

MassHousing Tenant Assistance
Awardees must use the Commonwealth’s secure Interchange system to submit all reporting. If you need technical support with accessing the Interchange system, please contact the Common Help Service Desk at 1-866-888-2808, 7:00am-6:00pm Monday through Friday, or at CommonHelpServiceDesk@state.ma.us.
HCII Awardees: Please refer to the deliverables schedule for any upcoming due dates for payment requests, Key Performance Indicators (KPI) submissions, or other deliverable requirements. No-cost extension requests are due 2 months prior to the end of your performance period. Please contact your HCII Point of Contact with any questions.
CHART Awardees: As described in the CHART Phase 2 Award Guide, submit monthly reports within 21 days of the close of each month. CHART Phase 2 reports with due dates that fall during a weekend or state holiday may be submitted before the due date or on the next business day after the weekend/state holiday. If you have questions regarding monthly reporting requirements during program closeout and no cost extension periods, please contact your Program Officer.
Health Policy Commission
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