June 3, 2019

Somebody to Lean On: The Community Partners Program

Joe* is a tall, African American man in his 50s who loves sports and spending time visiting local Boston attractions like the MIT museum and the New England Aquarium. Joe lives by himself, works part time as a janitor, and is saving up to go to a Sox game at Fenway Park. Joe has a complex medical history, including diabetes and several behavioral health diagnoses. He sees six different care providers and is on five different medications, not including an inhaler and the nicotine patch. Joe has trouble understanding complex ideas, and has some trouble speaking clearly. He spends most of his time in an adult day program. Joe’s mostly got it together, but he’s the kind of patient that could use a little extra help.

In March of 2018, Joe got a packet in the mail explaining that while he was still part of MassHealth (the Medicaid program for Massachusetts) he would now have his care coordinated by Partners HealthCare. The booklet explained that he was part of something called an Accountable Care Organization.

“See this card,” he says, pulling an insurance ID from his wallet that says Partners HealthCare Choice. “That means Partners takes care of me now. They’ve been really helpful.”

A New Way of Delivering Care

Accountable Care Organizations (ACOs) are a core component of the Affordable Care Act and a framework by which Partners HealthCare delivers value-based care. As an ACO, Partners-affiliated doctors, hospitals, and other health care providers come together to provide coordinated, high quality care to our patients. ACOs have agreements with insurance companies to provide special services and care coordination for certain patient populations. These agreements set performance standards for quality and spending, which in turn, provides either shared-savings incentives or penalties based on performance.

In March 2018, Partners HealthCare launched an accountable care organization (ACO) for Medicaid patients. One of the stated goals of the MassHealth ACO, Partners HealthCare Choice, is to improve access to quality health care, by providing services that meet patients “where they are.” To do this, Partners, along with other ACOs in the state of Massachusetts, are working with MassHealth to rollout new initiatives such as the Community Partners program, which aim to connect Medicaid patients with appropriate services and supports to complement their existing care plans.

Meeting Patients Where They Are

Community Partners (CPs) are community-based organizations that work with ACOs to provide care management and coordination to certain Medicaid patients. They are categorized as either Behavioral Health CPs or Long-Term Services and Supports (LTSS) CPs. Behavioral Health CPs help patients with significant behavioral health needs, including serious mental illness and addiction. LTSS CPs provide supports to certain members with complex, long term needs, such as children and adults with physical and developmental disabilities or brain injuries.

The Community Partners program launched at Partners on July 1, 2018, a few months after the initial Partners MassHealth ACO go-live. MassHealth developed a list of 27 agencies across Massachusetts offering Behavioral Health or LTSS supports. Now, when Partners receives a list of identified patients from the state, each patient is assigned to the appropriate Community Partner based on unique needs and geographic location.

“The community partners program can empower primary care physicians to better focus on providing care centered on the whole patient while simultaneously reducing administrative burden,” says Salina Bakshi, MD, Clinical Lead for the Community Partners Program at Partners HealthCare. “The deep relationships that the CPs have with their community provide a unique opportunity for the health care system to partner with community based organizations and improve delivery of high quality, integrated medical and behavioral health care.”

An Integrated Support System

Joe and Jamie near the Riverside office.

Joe works with Behavioral Health Community Partner Riverside, in partnership with the North Suffolk Mental Health Association. Joe’s Behavioral Health CP Care Coordinator Jamie Zarcaro has become like a life-coach, guiding him through situations big and small, with a focus on areas such as emotional management, interpersonal skills and self-advocacy. Zarcaro also helps to coordinate with Joe’s care team, so they are all aligned on his needs.

Joe’s Community Partner has helped coordinate with his day program to reach Joe’s goal of quitting smoking. She has also helped Joe stick to a weight loss plan—Joe has gone from 300+ pounds to 278 in a just a few months. They talk about managing his diabetes, how to use his new phone, his social activities, setting plans and goals, holidays, and ways to work in the community.

“Jamie helps me with stress,” says Joe. “That’s the most important thing, lowering my stress.”

Breaking New Ground

The Community Partners program is a five-year experiment for the duration of the initial MassHealth ACO. The goal is to improve collaboration across ACOs and community organizations, to break down barriers to care, and to deliver integrated care to address social determinants of health. These integrated clinical partnerships across organizations are unexplored territory, and all parties involved are learning as they go.

“We have overcome some of the initial operational challenges of implementing the Community Partners program as a part of the new MassHealth ACO,” says Esther Kim, Program Director for Accountable Care Organizations at Partners Population Health. “This is important work to help accelerate our continued focus on the whole person and care management of patients.”

For real-time feedback, MassHealth has implemented a consumer advisory council that meets directly with patients enrolled in the program to share their thoughts. Joe was chosen as one of the participants and feels good that his opinions are valued.

“It’s a new program and it’s shaping itself over time,” says Zarcaro. “Input from patients like Joe will help us hone in on where we can add the most value.”

Up Next: Explore our infographic to learn more about Community Partners.


 

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