Medicaid (MassHealth) patients are those enrolled in a joint state and federal insurance program for individuals and families with limited income and resources. After the passage of the Affordable Care Act (ACA) and the ensuing expansion of MassHealth, Massachusetts decided to distribute and share the responsibility, accountability, and financial risk for many of its patients with local health care systems. Mass General Brigham, like many health care systems, has evolved from a fee-for-service model into an Accountable Care Organization (ACO) where care is better coordinated, and physicians are rewarded for providing high quality care and improving patient outcomes while keeping costs under a target. The Partners HealthCare MassHealth ACO, Partners HealthCare Choice, launched in March 2018, which covers approximately 106,000 patients.

Addressing the Needs of the Whole Patient

A growing focus of our work in the Medicaid ACO is not only to mitigate medical problems, but to find ways to address the needs of the whole patient, also referred to as Social Determinants of Health. While the delivery of health care is essential to staying healthy and getting well, it is not the only “determinant of health.” Other factors such as psychosocial factors and environmental conditions in which people live, work, and age can have a far greater impact. Existing evidence has found that targeting social determinants of health like housing and food, is effective in improving patient health outcomes and decreasing healthcare costs. To target these issues, Population Health has rolled out a suite of programs that screen for challenges in these social conditions, connect patients with appropriate services, and leverage existing community-based programs to support patients in meaningful ways. This approach has also resulted in an expansion our high-risk care management programs, behavioral health supports, and substance use initiatives. Together with the state and our community partners, we are trying to move the dial forward in caring for our most vulnerable population.

Social Determinants of Health Screenings

Mass General Brigham is implementing a system-wide Social Determinants of Health Screen in the primary care setting to identify patients’ health-related social needs such as housing and food insecurity and to refer them to appropriate resources. In March 2018, the Medicaid ACO launched a system-wide Social Determinants of Health (SDOH) Screening and Referral Program at all Mass General Brigham adult and pediatric primary care practices. The 13-question survey, which was developed by Mass General Brigham clinical leaders, in collaboration with other local institutions such as Boston Medical Center, has been implemented with the goal of addressing modifiable risk factors and improving quality of care for Medicaid ACO patients who present in primary care for new patient, annual physical, and non-urgent follow-up visits. The screen focuses on factors including: transportation, food, housing, employment status, education, care of a family member, and paying for medications. The screening results are integrated into the Electronic Medical Record (EMR) where patients can be referred to appropriate local staff, such as a community health worker or provided with information on available resources. To meet the social needs identified in the screening (such as housing or food insecurity) primary care sites rely heavily community health workers, social workers, community resources specialists, or equivalent roles to connect patients to appropriate internal or community-based resources.

Emergency Department (ED) Navigator Pilot Program

Emergency Department (ED) Navigators work to meet patients in the ED and connect them to supports and programs across the system and in the community. In March 2018, the Partners HealthCare Medicaid ACO launched the Emergency Department (ED) Navigator Pilot Program at three sites including Brigham and Women’s Hospital (BWH), Massachusetts General Hospital (MGH), and North Shore Medical Center (NSMC). The pilot features an ED Navigator at each site who is able to have an in-depth meeting with the patients and to provide tailored care coordination and connections to resources to address patients’ unique needs. The pilot targets Medicaid ACO patients who present in the ED with lower acuity medical concerns and who would benefit from connection to primary care, long term care management, and/or access to health-related social services. Specifically, the ED Navigator focuses on connecting Medicaid ACO patients presenting in the ED to:

  • Their primary care doctor and clinic;
  • Appropriate Population Health programs including, but not limited to: High-Risk Care Management, Collaborative Care, and Substance Use Disorder Recovery Coaches;
  • Resources and supports to address health-related social needs.

Managing ED utilization is a critical pillar of the Medicaid ACO clinical strategy. The focus is to engage members that are not connected with primary care where many population health resources are embedded, but to instead meet them in the ED. Other related Emergency Department interventions have shown a reduction in return emergency visits, hospitalizations, and total costs of care, along with improved primary care engagement and utilization of less acute care settings. The ED Navigator pilot is a unique opportunity to engage provide additional support to a particularly vulnerable patient population with historically high emergency department utilization.

Expanded Behavioral Health Programs & Resources

As part of the Medicaid ACO, Population Health has expanded many of our existing behavioral health and substance use disorder programs. Learn more about these programs under the Behavioral Health & Substance Use “Patient Intervention” section.

  • Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) is a short term behavioral health intervention used in primary care that includes screening for symptoms, coaching, behavioral activation, psychoeducation, support with medication adherence, and psychiatric consultation in a treatment-to-target approach.
  • Screening, Brief Intervention and Referral to Treatment (SBIRT) is a one-time, sequenced intervention with patients that screens for substance use, provides targeted education about substance use and mental health, and refers patients as needed to substance use disorder treatment.
  • Internet-based Cognitive Behavioral Therapy (iCBT) is an online, self-directed course in cognitive behavioral therapy (CBT), for patients with low to moderate levels of depression, anxiety, and related conditions, that helps them self-manage symptoms of those conditions.
  • Resource-Finding help patients find community-based mental health therapists, psychiatrists, or behavioral health treatment programs.
Social Work Care Management

Social Work Care Management is individualized outreach and engagement with certain Medicaid patients who have behavioral health risks to foster access to needed community resources for addressing social determinants of health and overall coordination of care. Social Work Care Management is developed from evidence-based models designed for health care settings, many of which are codified for practice by the National Association for Social Work (NASW), that have expanded nationwide for both Medicaid and Medicare patients. For certain members of the Medicaid ACO with behavioral health risks, Social Work Care Management assertively reaches out to engage patients. These members include patients presenting at emergency departments without connections to their primary care physicians and those with unmet behavioral health needs. The care management program includes assessment, problem solving, referrals, advocacy, and long-term connections to primary care for these patients. The social worker care manager may be deployed to play a role with certain ACO primary care patients that are seeing a psychiatrist regularly, but who have barriers to accessing this specialty care. For such patients, the social work care management intervention is used to increase the likelihood that a patient has the stability and resources to attend specialty appointments, communicate with their psychiatrist, and comply with psychiatric treatment.

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