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Massachusetts Health Policy Commission
Summer 2018
This summer newsletter features the Health Policy Commission’s ongoing support of work that advances behavioral health integration within medical care systems in the Commonwealth. We are pleased to share the announcement of awards in the HPC’s newest investment program, the SHIFT-Care Challenge. SHIFT-Care awards will fund initiatives focused on addressing the health-related social needs of complex patients and providing timely access to behavioral health services, particularly evidence-based treatment for opioid use disorder. This edition also highlights HPC awardees, the Brookline Center for Community Mental Health and Beth Israel Deaconess Hospital-Plymouth, and their work on integrating behavioral health care for their patie nts. Finally, we are excited to announce the upcoming release of several HPC publications: profiles of the 17 HPC-certified Accountable Care Organizations (ACOs).and a policy brief “Transforming Care: How ACOs in Massachusetts Manage Population Health.” 

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
The SHIFT-Care Challenge: HPC Announces 15 Awardees Selected to Implement Innovative Care Delivery Models across the Commonwealth 
The HPC Board approved 15 awardees for the SHIFT-Care Challenge at the agency’s July 18th public meeting. Through SHIFT-Care, the HPC will distribute nearly $10 million in funding to innovative care delivery transformation initiatives from Massachusetts providers. Representing each region of the Commonwealth, SHIFT-Care Challenge initiatives aim to reduce avoidable acute care utilization by investing in evidence-based, innovative care delivery models that are community-based, collaborative, and sustainable. Awardee initiatives are focused on addressing the health-related social needs of complex patients or providing timely access to behavioral health services. A description of each initiative’s care model can be found here .  
The SHIFT-Care Challenge is intended to foster stronger partnerships between community-based organizations and health care providers, including ACOs and hospitals. The goal is also to contribute to the emerging evidence that addressing health-related social needs and providing timely access to behavioral health services can result in overall cost savings to the health care system, through a reduction in acute care utilization. The HPC anticipates programs launching in late fall 2018.
Addressing the health-related social needs of complex patients.
The goal of these projects is to support innovative care models that address health-related social needs of complex patients to prevent avoidable admissions, readmissions, emergency department (ED) visits, and/or ED revisits. 

The HPC is funding five awards with this focus, totaling $3,288,234:
  • Community Care Cooperative (C3)
  • Boston Medical Center
  • Hebrew SeniorLife
  • Baystate Health Care Alliance
  • Steward Health Care Network, Inc.
Providing timely access to behavioral health services.
These awards support innovative models that enable timely access to behavioral health services in order to prevent avoidable admissions, readmissions, ED visits, and/or ED revisits. A majority of these initiatives focuses specifically on expanding access to treatment for opioid use disorder by implementing models of care that initiate evidence-based pharmacologic treatment in the ED and connect patients to outpatient services for ongoing treatment. 

The HPC is funding ten awards with this focus totaling $6,467,066:
  • Holyoke Health Center
  • Lowell General Hospital
  • Massachusetts General Hospital
  • North Shore Medical Center
  • UMass Memorial Medical Center
  • Beth Israel Deaconess-Plymouth
  • Addison Gilbert/Beverly Hospitals
  • Harrington Memorial Hospital
  • Mercy Medical Center
  • Holyoke Medical Center

The Brookline Center for Community Mental Health: Strong, Effective Communication and

As an awardee of the HPC's Targeted Cost Challenge Investment (TCCI) program, the Brookline Center for Community Mental Health (BCCMH) has partnered with the Beth Israel Deaconess Care Organization (BIDCO), an HPC-certified ACO, and Springwell, an Aging Services Access Point (ASAP). Their initiative aims to reduce total health care expenditures by 15% for adult patients of BIDCO with a chronic medical condition and a behavioral health condition. To achieve this goal, BCCMH deploys a mobile multidisciplinary care management team to integrate behavioral health, primary care, and health-related social needs such as housing. This TCCI-funded work builds on the successful “Healthy Lives” pilot program that these partners collaborated on previously.
Integration of BIDCO primary care with behavioral health care services offered at BCCMH has been a primary component of this partnership. Forming new relationships and strengthening existing relationships with primary care providers (PCPs) in the community has increased appropriate referrals of eligible patients to BCCMH's TCCI-funded program. The BCCMH team has prioritized outreach to PCPs in the community in partnership with their ACO, BIDCO, to communicate about the services its program provides, the patient population it works with, and who should be contacted for more information or to make a referral.

The BCCMH team communicated early and often with their partner organizations to understand which providers in the community should be targeted. The team leveraged existing relationships to forge new ones and to create a strong referral network. This consistent communication and outreach to local providers has resulted in the program becoming a well-known and highly sought after resource in the community.

To create and solidify connections with PCPs, team members attended meetings at participating primary care practices to introduce the BCCMH program and the staff. BIDCO and Springwell staff with existing relationships with new PCPs facilitated introductions and provided valuable insight into best practices for communication. The BCCMH team held a refresher meeting over the holidays, touring the practice sites and leaving literature about the program (and cookies!). This resulted in several referrals and improved clarity regarding eligibility criteria, services provided, and the referral process. Increased and consistent communication with new providers helped create a strong foundation for this new network of integrated care.
The BCCMH team streamlined its referral system, so that providers knew where to direct questions. The team began providing program criteria and referral information to BIDCO’s nurse care management staff, based at primary care sites, for inclusion on the care management referral sheet. Receiving this completed form as part of a referral greatly improved introductory knowledge of a patient, and allowed for more targeted goal setting and interventions during a new patient’s initial meeting with the BCCMH team. Additionally, the team worked with BIDCO to ensure that providers referring patients to care management are automatically offered a referral to Healthy Lives.

Patients referred to BCCMH's initiative by the BIDCO nurse care managers or PCPs were more likely to enroll and engage in behavioral health care services. A referral-based model has allowed the team to introduce the program in partnership with the patient’s referring PCP. In initial telephone calls the BCCMH team can say, “You were referred to us by Dr. Jones, who thought you might find our services helpful.” This has created trust and built rapport with new patients.

As a result of these thoughtful approaches to program outreach, communication, and visibility, referrals to the BCCMH program have significantly increased and it now has a waitlist. The team continues to engage in process improvement efforts, such as clarifying the eligibility criteria, to reduce the number of patients on the waitlist. Engagement rates have also greatly improved, and the BCCMH TCCI team has been able to expand its service area to include a total of 14 communities throughout Boston and the Metro West region. With this expansion, the team members have continued to focus on deepening their knowledge of community and health care resources, and fostering access to better care at a lower cost. 
Beth Israel Deaconess Hospital-Plymouth: Care Coordination through CHART
Thr ough the CHART program, the HPC supported Beth Israel Deaconess (BID) Hospital-Plymouth’s initiative to reduce readmissions for patients with dual eligibility for Medicare and Medicaid and to reduce ED revisits for patients who visit the ED with a primary behavioral health diagnosis. Members of the BID-Plymouth CHART team shared a patient story highlighting how their programs co ordinated care for patients with complex medical and behavioral health needs to improve patient outcomes and experience. 

The patient was a young adult with co-occurring substance use disorder (alcohol and IV heroin use), complex mental health needs, and serious chronic medical conditions. The patient began using alcohol at a young age, and had only experienced sobriety while briefly in jail and on probation. Despite efforts to connect to behavioral health providers, he faced challenges in achieving consistent attendance at those appointments. He also repeatedly visited the ED which often resulted in hospital admissions.

When he was identified for the program, he was so ill that he could barely complete the outpatient behavioral health intake assessment. Recognizing an opportunity to coordinate and accelerate care for the patient, the CHART program’s social worker coordinated with his PCP’s assistant, and was able to offer expedited access to the appropriate specialist. This not only provided needed care, but demonstrated the CHART team’s dedicated efforts to support the patient. 

Following these care coordination efforts, the patient was much more receptive and engaged with the CHART team, completing behavioral health visits with the team’s social worker and nurse practitioner. He attended biweekly therapy sessions, and started antidepressant medication. Though he was initially unwilling to engage in Alcoholics Anonymous or take medication to help with alcohol cravings, as his overall health, anxiety and mood improved, he was receptive to trying medication for alcohol dependence and responded positively.

The patient experienced additional benefits, and appeared to be less socially isolated, more connected with family and friends, less stressed, and quit smoking. Several months after engaging with the CHART team, the patient has not had any return visits to the hospital. His PCP reported that his physical health was stable and that his chronic conditions were well controlled, a remarkable achievement considering the complex interaction between his medical and behavioral health conditions.
Coming Soon: ACO Certification Policy Brief on Population Health Management
The HPC is pleased to announce the forthcoming publication of a new policy brief “Transforming Care: How ACOs in Massachusetts Manage Population Health”. The second in a series reporting findings from the HPC ACO Certification program , this latest brief describes how ACOs routinely conduct risk stratification to understand their patient population needs and to implement programs designed to address those needs, particularly in the areas of behavioral health and social determinants of health. The brief concludes with some recommendations for how providers, payers, and policy makers can support more effective population health management approaches and programs.

The HPC is also preparing to publish ACO Profiles – one-page descriptions of the 17 HPC-certified ACOs. Each profile will provide basic information about the ACO, such as the payers with which it has risk contracts and whether it is anchored by a physician group, teaching hospital, or community hospital, based on publicly-reported information submitted to the HPC in 2017 ACO Certification applications. Where applicable, the profiles will also provide data about the larger health system of which the ACO is a part, sourced from 2017 Massachusetts Registration of Provider Organizations (RPO) filings.

The HPC expects to post the policy brief and profiles on our website later this summer. Visit the site now to read the first ACO Policy Brief and view other resources on the ACO Certification program. 
August 16, 2018
12:30pm - 2:00pm EST

Boston, MA
August 28 - August 30, 2018
All day

September 11, 2018
1:00pm - 2:30pm EST

September 14, 2018
8:30am - 3:00pm EST

Framingham, MA
September 27, 2018
8:00am - 2:30pm EST

Harvard Medical School Center for Primary Care and Philadelphia College of Osteopathic Medicine
Boston, MA
October 5, 2018
Summer is a great time to catch up on your reading! We’d like to offer the following publications and books to add to your list:

Being Mortal: Medicine and What Matters in the End by Atul Gawande  

Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones

Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations by Ezekiel J. Emanuel

Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives by Tom Farley

Stories from the Shadows: Reflections of a Street Doctor by James J. O'Connell

The American Health Care Paradox: Why Spending More is Getting Us Less by Elizabeth H. Bradley and Lauren A Taylor

Women in Science: 50 Fearless Pioneers Who Changed the World by Rachel Ignotofsky
Health Policy Commission
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