Massachusetts Health Policy Commission
January 2018
The Health Policy Commission (HPC) is excited to announce the launch of Transforming Care, a monthly newsletter to share care delivery insights and resources from our Certification and Investment Programs. Given the overlap in audiences and topics of interest across our programs—from complex care management to behavioral health integration to accountable care organizations—this newsletter will serve as a platform to share related HPC news and care delivery transformation lessons from the field.

We welcome your input and recommendations for making this newsletter as relevant and useful as possible; please email us at
New grant opportunity: SHIFT-Care
We're kicking off 2018 with a new grant opportunity. In early January the HPC announced the next round of funding through its Health Care Innovation Investment (HCII) Program: The SHIFT-Care Challenge. 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 has issued a Request for Proposals (RFP) for organizations to apply for funding. The deadline for eligible proposals is April 6, 2018.
Treating Opioid Use Disorder in Primary Care
The HPC recently released an infographic on strategies for treating opioid use disorder (OUD) in primary care based on insights from a peer-to-peer learning session. In 2017, the HPC hosted a panel discussion featuring Massachusetts providers with experience treating OUD in primary care settings. The infographic presents key insights from the event, including examples of OUD treatment models and recommendations from clinical experts on getting started with treating OUD in primary care. Please click here to view the infographic.
Care Delivery Resources to Guide Your Work in 2018
2018 is expected to be another significant year for the advancement of approaches to addressing the behavioral and health related social needs of patients in Massachusetts. Check out several leading resources below:
Lessons Learned from Community Hospital Care Delivery Redesign Initiatives: CHART Phase 2 Statewide Convening
On October 16, 2017, the Health Policy Commission held its second CHART Phase 2 Statewide Convening to highlight some of the successes, challenges, and lessons learned from the individual and collective work of the two-year, $60 million investment in 25 programs across 27 community hospitals to improve care for high risk and vulnerable populations. This full-day public event included panel discussions and breakout sessions during which attendees heard directly from care team members, program managers, and hospital leadership implementing these initiatives. Check out the materials from the event:
Guidebook to Social Services for MassHealth ACOs
Last summer, the Blue Cross Blue Shield of Massachusetts (BCBSMA) Foundation released  A Guidebook to Social Services for MassHealth ACOs . The guidebook provides an overview of the types of social services available in Massachusetts, including organizations that provide these services and their key funding sources. This overview is intended to serve as a knowledge base for health care administrators and providers as organizations, especially MassHealth ACOs, who seek to identify, coordinate, and integrate with available social service resources. 
Understanding the Behavioral Health Care System in Massachusetts
The BCBSMA Foundation also published a report titled  Access to Behavioral Health Care in Massachusetts: The Basics.  This report provides a background on the behavioral health system in Massachusetts, including an overview of policy changes and trends in mental health and substance use disorders (with data analysis from the HPC). The report also describes specific data on four primary factors affecting access to behavioral health services: workforce capacity, system capacity, affordability, and quality. 
Designing and Delivering Whole-Person Transitional Care:
The Hospital Guide to Reducing Medicaid Readmissions
The Agency for Healthcare Research and Quality (AHRQ) published a hospital readmissions reduction guide,  Designing and Delivering Whole-Person Transitional Care . Referenced by many CHART Phase 2 awardees during their care delivery redesign programs, the guide includes 13 tools , ranging from data analysis to dashboard redesign to transitional care planning. These can be individually downloaded and tailored to program-specific needs. 
Securing housing for patient health
Commonwealth Care Alliance’s (CCA) Targeted Cost Challenge Investment award is a $1.1M “Ambulatory ICU” initiative aimed at providing integrated primary and behavioral health care to fill gaps in health and social services for patients with complex needs. The team recently shared a story of a chronically homeless CCA member who was able to secure housing with the assistance of CCA health outreach workers (HOWs).  

The CCA member has struggled with housing for most of his life. After an extended period of living on the streets, he was recently reached by a CCA HOW, who began meeting with him regularly to establish rapport. They quickly started submitting applications for housing, and made progress with one of the available housing options, an assisted living community. The HOW assisted the individual throughout the application process, including filing the correct paperwork, ensuring that all assistance was member-directed. In other words, the member was the one who determined the level of support he received at all times. Less than six months after the original application—unlike the typical one to three-year wait for similar housing situations—the individual advanced to the next step in the housing process: an interview. Again, under the direction of the individual, the HOW assisted her client with interview preparation, resulting in a successful interaction. Following the interview, the individual’s Section 8 voucher still needed to be approved. After three uncertain and anxious months following the interview, the facility offered a place to the individual.

However, another bureaucratic complication arose due to his history of frequent address changes. The HOW continued supporting and advocating for him as he requested assistance. After another administratively-intense week, the individual finally received sign-off and moved into the facility that same day. After many months, he is now successfully housed in an assisted living facility where he can receive the support he needs with less intensive case management services by the HOW.
HPC Certifies 17 Accountable Care Organizations (ACOs)
On January 4, the HPC announced that 17 health care organizations have met the requirements of its Accountable Care Organization (ACO) Certification program and are HPC-certified ACOs. The first round of ACO Certification is a significant milestone and makes Massachusetts the first state to implement state-wide, all-payer standards for care delivery. The organizations that met the certification requirements are:
  • Atrius Health, Inc.
  • Baycare Health Partners, Inc., inclusive of Pioneer Valley Accountable Care, LLC; and Baystate Health Care Alliance, LLC
  • Beth Israel Deaconess Physician Organization, LLC (Beth Israel Deaconess Care Organization)
  • Boston Accountable Care Organization, Inc.
  • Cambridge Public Health Commission D/B/A Cambridge Health Alliance
  • Children’s Medical Center Corporation, inclusive of Children’s Hospital Integrated Care Organization, LLC; and Boston Children’s Health Accountable Care Organization (Boston Children’s Accountable Care Organization)
  • Community Care Cooperative, Inc.
  • Lahey Health System, Inc., inclusive of Lahey Clinical Performance Network, LLC; and Lahey Clinical Performance Accountable Care Organization, LLC
  • The Mercy Hospital, Inc., inclusive of Mercy Health Accountable Care Organization, LLC; and Riverbend Medical Group, Inc.
  • Partners HealthCare System, Inc., inclusive of Partners HealthCare Accountable Care Organization, LLC
  • Reliant Medical Group, Inc., inclusive of Fallon 365 Care
  • Signature Healthcare Corporation D/B/A Signature Healthcare
  • Southcoast Health System, Inc., inclusive of Southcoast Accountable Care Organization, LLC; and Southcoast Health Network, LLC
  • Steward Health Care Network, Inc., inclusive of Steward Integrated Care Network, Inc.; and Steward Medicaid Care Network, Inc.
  • Wellforce, Inc., inclusive of Wellforce Care Plan, LLC; Lowell General Hospital/Lowell General Physician Hospital Organization; Circle Health Alliance, LLC; New England Quality Care Alliance, Inc.; and NEQCA Accountable Care, Inc.

In addition, the following organizations achieved provisional ACO Certification, which is for organizations without prior risk contracting experience that will begin operating as ACOs in the new MassHealth ACO program in 2018:
  • Health Collaborative of the Berkshires, LLC
  • Merrimack Valley Accountable Care Organization, LLC
Health Care Innovation Investment - Telemedicine Pilot:
Heywood Hospital
Rebecca Bialecki, Vice President of Community Health Initiatives of Heywood Hospital and Investment Director for Heywood Hospital's Telemedicine Award , presented at the Annual Mid-Winter Leadership Forum  hosted by Massachusetts Health & Hospital Association on January 26. The Forum addressed pertinent legal and regulatory issues for hospital leaders, including telemedicine.

Ms. Bialecki contributed to a panel titled,  Telemedicine: Healthcare's Biggest Game Changer? Key takeaways from the panel included:

  • To ensure adoption, align the use of telemedicine to support the goals of the health care provider or entity. Incorporate champions across departments and roles (e.g., physician, nursing, regulatory, billing, etc).
  • Telemedicine access varies across urban and rural settings. Statewide access to telemedicine through policy will still require infrastructure improvements in many rural communities for effective use of the technology.
  • Efforts towards reimbursement parity continue to lag behind telemedicine demonstrations of effectiveness and value to patients.
SDOH Academy
February 8, 2018 (3-4pm EST)
Part of a 6-month virtual training series
Center for Health Care Strategies
February 14, 2018 (11:30am -1:00pm EST)
Massachusetts Health Data Consortium
Waltham, MA (9-11am EST)
March 1, 2018
Institute for Healthcare Improvement
Boston, MA
March 12, 2018
Massachusetts Health & Hospital Association
Burlington, MA
March 16, 2018
HPC Special Event:
Partnering to Address the Social Determinants of Health
Health Policy Commission
UMass Club, One Beacon St
Boston, MA
May 17, 2018 (8:30am)
Coming soon! PCMH PRIME Practice Coaching to support behavioral health integration (BHI) into primary care.
The HPC will offer practices that are participating in PCMH PRIME Certification the chance to apply to receive up to 20 hours of free expert coaching on BHI topics of their choice, including workflow design, financial management, telehealth program planning. Email for application instructions.
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.
Institute for Healthcare Improvement
Institute for Healthcare Improvement
Bureau of Substance Abuse Services
Massachusetts Department of Public Health
Massachusetts Association of Community Health Workers
Boston University School of Social Work
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
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. 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
50 Milk Street, 8th Floor
Boston, MA 02109