Having trouble viewing this email? Click here
Massachusetts Health Policy Commission
September 2018
This month’s newsletter features the Health Policy Commission’s work with accountable care organizations (ACOs) in Massachusetts. We are excited to highlight new publications that describe the 17 HPC-certified ACOs, share the work of CHART awardee Southcoast Hospitals Group as they translate lessons from their CHART experience to their MassHealth ACO model, and relay the success of Targeted Cost Challenge Investment (TCCI) awardee and ACO Boston Medical Center in high-touch care coordination and patient navigation.

Let us know if there are other care delivery transformation topics or work in the Commonwealth that you would like to see the HPC showcase in this newsletter. We'd love to hear from you! Email us at caredeliverytransformation@mass.gov .
Team HPC
Accountable Care Organizations in Massachusetts: Profiles of the 2017-2019 HPC-certified ACOs
A new publication from the HPC provides key facts about each of the HPC-certified ACOs in Massachusetts. In early September, the HPC issued ACO Profiles , which provide overviews of the 17 certified ACOs to increase transparency and public understanding about these organizations.

The ACO Profiles highlight selected information about each ACO and, where applicable, the larger provider organizations of which they are a part, such as:
  • The payers with which the ACOs have risk contracts;
  • The areas of the state in which they provide care;
  • Their approximate size; and
  • Whether they are anchored by a teaching hospital, a community hospital, or a group of physicians.
Key data sources for the profiles include non-confidential information submitted to the HPC for ACO certification and other public data sources such as the Massachusetts Registration of Provider Organizations ( MA-RPO ) program. Details about the HPC’s data sources and methodology for creating the profiles are provided at the end of the publication. 
The ACO Profiles are part of a series of policy briefs and other resources that the HPC is issuing to provide stakeholders and the interested public with new information and insights regarding HPC-certified ACOs. This September the HPC also released its second brief, “Transforming Care: How ACOs in Massachusetts Manage Population Health.” Y ou can find the profiles, as well as the ACO policy briefs and other materials, on our website, Transforming Care: ACO Briefs and Other Resources .  
We welcome your feedback on the profiles, briefs, and other resources! Share your thoughts with us via our dedicated certification mailbox, HPC-Certification@mass.gov .
From CHART to ACO: The Experience of Southcoast Hospitals Group
The HPC developed the Community Hospital Acceleration, Revitalization, and Transformation (CHART) program with the goal of advancing community hospitals’ population health capabilities and as preparation for performance in alternative payment models (APMs). One awardee, Southcoast Hospitals Group (“Southcoast”), shared its strategy for translating the capabilities and infrastructure developed through the CHART program to its participation in the MassHealth ACO .
In the CHART program, awardees were asked to prepare strategic plans for sustaining services and leveraging the CHART operational experience in APMs. In its strategic plan, Southcoast outlined its commitment to integrating many key processes from CHART into permanent, cross-continuum structures within the organization’s ACO for patients with significant medical, behavioral, and social needs.
Southcoast’s CHART program was designed to enhance care for patients who frequently seek care in the emergency department (ED) or have a history of repeated hospitalizations. The service model involved a multidisciplinary “MyCareTeam” including a physician, nurse practitioner/physician assistant, licensed social worker with a behavioral health background, nurse care manager, community health worker, staff nurse, and clinical pharmacist. Services included integrated behavioral health care, medical care, social work, pharmacy, health literacy education and care navigation.
Southcoast engaged key stakeholders across the organization, including the Southcoast Health President and CEO, the Chief Operating Officer and other senior leaders, to convert the CHART service model into sustainable structures and patient services. The organization committed to two systems-level interventions for sustainability: maintenance of the MyCareTeam model and integration of behavioral health services within Southcoast’s ambulatory care practices.
Essential resources for these services will be provided by Delivery System Reform Incentive Payment Program (DSRIP) funding as part of Southcoast’s MassHealth ACO, in partnership with Boston Medical Center HealthNet. Eighteen employees from Southcoast’s CHART program transitioned into the same or similar roles on the ACO’s Care Navigation team. These roles include nurses, licensed social workers, community health workers, a community resource specialist, and a data analyst to sustain key processes determined to be significant contributors to positive results for Southcoast’s CHART patients. As staff from Southcoast explained in an interview,

[T]he creative approach we took to care delivery was folded into the ACO opportunity. CHART informed the development of a population health strategy and became the foundation of clinical operations for the ACO. In restructuring our care management system, CHART helped prove the value of the community health workers, social workers, and [the approach of] working with patients in the community .”
Simultaneously, the CHART behavioral health nurse practitioner and a licensed social worker are in the process of establishing part-time services within primary care provider practices to support Southcoast’s behavioral health integration effort.
Technology will play an important role in the ongoing care model. Southcoast expressed that staff “ [entered] into the ACO knowing the importance of data and the need to compile a lot of data from different places to identify high risk patients .” Southcoast continues to use its electronic health record data and data warehouse tools to analyze data around care management.
Southcoast also developed and improved connections to community-based organizations during CHART that inform its ACO strategy and operations. One program manager noted that “ We connected with 75 different organizations on a first name basis under CHART .” Empowered by an ability to engage a large number of community partners under CHART, Southcoast expressed confidence that relationships with ACO-selected behavioral health and long-term services and supports community partners would be successful in addressing MassHealth patients’ needs.
According to Southcoast, “[T]he learnings and information gathered throughout the CHART process was truly invaluable, and served as the underlying basis for the development of our revised Care Navigation structure .” Southcoast continues to apply the principles of continuous quality improvement to its care model, a competency enhanced by its participation in CHART.
Care Coordination and Patient Navigation: High Touch High Trust at Boston Medical Center
Through the Health Care Innovation Investment Program (HCII) , the HPC supports Boston Medical Center (BMC) and Medical- Legal Partnership Boston’s (MLPB) High Touch High Trust (HT2) Initiative to reduce avoidable acute care utilization. BMC is also an HPC-certified ACO . The HT2 initiative is a high-touch care coordination model that deploys community health advocates (CHA) to engage patients in the ED. Before engaging patients, the CHAs receive education on how health-related social needs impact health outcomes by legal aides from MLPB. The CHAs work with patients to address their health-related social needs by linking them to community services and primary care, while the legal aide team helps address their legal-related needs.
The HT2 team shared a patient story highlighting how the program coordinated care for a patient with complex health-related social needs, as well as medical and behavioral health conditions to improve patient outcomes and experience:
A patient with a history of frequent ED visits and hospital admissions presented at BMC’s psychiatric ED. The patient was identified as a candidate for the HT2 program, and a program CHA met the patient and enrolled the patient in the program. The CHA engaged with the patient to assess current needs, which included medical conditions and mental and substance use disorders, all exacerbated by an unstable housing situation. The patient, who was smoking a pack of cigarettes per day, had been diagnosed with lung nodules and lesions and had a goal of improving lung health. The patient was living in a transitional housing facility and reported feeling no hope of ever leaving for permanent housing. The patient struggled with despair, drinking daily and having frequent confrontations with staff and tenants at the housing facility.
After being discharged from BMC, the CHA conducted a home visit to get a better sense of the patient’s living environment. The CHA first worked with the patient at home, understanding the patient’s living situation and developing a relationship. The CHA transitioned to scheduling times for the patient to “get out of the house” and visit the CHA at BMC. Gradually, the CHA was able to enroll the patient in a weekly program that provided access to use of a pool, gym, and group meetings. The patient began leaving the apartment more and reported feeling more enjoyment, and less fixation on other tenants’ behavior, which allowed the patient to focus on healthy activities and participation in the community, such as going to the gym regularly and enrolling in a computer course.
Simultaneously, the CHA worked with the patient’s primary care team to coordinate the patient’s medical care and scheduling, resulting in the patient’s regular attendance at visits with the pulmonology, primary care and psychiatric teams.
With the support of the HT2 program’s holistic approach to identifying patient needs and goals, and CHAs who are trained to support a wide range of health-related social needs and work where patients need them, this patient is now in substantially better physical health, according to medical providers, and also achieved several of important goals—the patient now smokes only half a pack per day, has lost weight, and is taking active steps towards finding permanent housing.
Hebrew SeniorLife Presents at the National Home and Community Based Services Conference
The HPC is pleased to congratulate the Hebrew SeniorLife (HSL) team on presenting their TCCI Program , the Right Care, Right Place, Right Time (R3) program, at the National Home and Community Based Services Conference in Baltimore last month. HSL presented interim results of their R3 program, which includes reductions in unnecessary ambulance trips to acute care and transitions to costly long-term care, to a well-attended session on “New Models of Affordable Senior Housing-Based Service Coordination/Wellness Programs.” HSL presented to an audience eager to learn how to replicate R3 in other states, and were joined on the panel by Mark Cohen, the principal investigator of their program evaluation from UMass Boston, LeadingAge Long-Term Services and Support (LTSS) Center, a policy partner, and Vermont’s Support and Services at Home (SASH) Program, which served as a reference model for HSL’s original TCCI Proposal.
Brookline Community Mental Health Center Presents to HPC Board
Staff from the Brookline Community Mental Health Center (“Brookline”) presented on their TCCI program at the September 12 th HPC Board Meeting. The Board heard from Dr. Henry White and Ms. Hannah Scott who shared early results from their TCCI Healthy Lives program. The initiative, which began in July 2017 and will continue until December 2018, deploys a multidisciplinary care management team into the community and patients' homes, and aims to reduce acute care utilization costs by 15% by helping patients navigate medical care, behavioral health care, and community resources. Interventions are led by community health workers, and focus on creating a shared, integrated understanding of the patients in order to address their comprehensive needs. Notably, over nine months of enrollment, 68% of patients showed improvement in relevant health outcomes, and patients reporting homelessness or housing instability decreased from 18% to 2%. After hearing about a number of individual patient experiences and the program's highly successful outcomes related to reductions in inpatient and ED utilization and 30-day readmissions, HPC Vice Chair Dr. Wendy Everett thanked Brookline staff for their insights and on-the-ground contributions to care delivery innovation, noting the significance of "what [Brookline] has been able to do with a small amount of grant money within [the HPC's] innovations program." To learn more about Brookline's program, please see their slide presentation here . A video of the Board meeting can be seen here
Health Policy Commission
Boston, MA
September 27th, 2018

Health Policy Commission
Boston, MA
October 3rd, 2018

Harvard Medical School Center for Primary Care and Philadelphia College of Osteopathic Medicine
Boston, MA
October 5 th, 2018

Health Policy Commission
Boston, MA
October 10th, 2018

Health Policy Commission
Boston, MA
October 16 th and 17 th

Personal Connected Health Alliance
Boston, MA
October 17th--19th

Massachusetts Health & Hospital Association
Burlington, MA
October 19 th, 2018

Massachusetts Medical Society
Waltham, MA
October 25 th, 2018
BCBSMA Foundation
Center for Health Care Strategies

Health Affairs Blog

National Association of Accountable Care Organizations
Application Deadline: November 1 st , 2018


Bureau of Substance Abuse Services
Massachusetts Department of Public Health

Massachusetts Association of Community Health Workers
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109