Competency Area #3: Access, apply, and exchange data across all entities involved in MassHealth member wellness and care

The key elements that comprise Competency Area #3 are outlined below. These can be used as touchpoints in determining whether your TA project helps advance your ACO or CP in this competency.

Core Competency #3

Access and apply data in support of care design, quality improvement, risk stratification, and overall organizational decision making: ACOs and CPs access and apply MassHealth member data within their organizations in order to ensure that models of care, quality improvement activities, risk stratification models, evaluation approaches, and organizational decision making overall are grounded in a data-driven understanding of the health and social needs, complex care needs, and overall characteristics and preferences of the unique population(s) of MassHealth members they serve.

Exchange data with all entities involved in the care of MassHealth members: ACOs and CPs exchange MassHealth member data, as appropriate, across all entities involved in member wellness and care, including hospitals, specialist providers, oral health providers, state agencies, social service agencies, and community-based organizations, as well as the entities that comprise the ACO or CP, in order to ensure comprehensive, coordinated care and services for every MassHealth member enrolled in their ACO or CP.

ACO/CP Integration: ACOs and CPs exchange and apply MassHealth member data across ACO-CP partnerships in order to ensure that MassHealth members with complex behavioral health, long-term services and supports, and health-related social needs benefit from comprehensive and seamless systems of care.

Previous: Competency Area #2 * Next: Competency Area #4

Optimize Information Exchange between CP and established community linkages: An ACO and CP combine their TA allocations and propose a joint TA project to review the Documented Processes related to data translation, health data exchange, event notification, and future referrals to identify ways to improve and streamline shared workflows. The TA vendor facilitates discussions between the ACO and CP to establish comprehensive and coordinated workflows, while being cognizant of the distinct ACO and CP cultures. This project also addresses Competency Areas #1 and #5 in that it improves the ACO’s and CP’s ability to provide seamless systems of care for MassHealth members with complex needs.

Leverage an electronic data reporting system across ACO’s CHCs: An ACO engages a TA vendor to support the implementation of workflows related to the electronic data reporting system at the ACO’s community health centers (CHCs). Some of the ACO’s CHCs have experience with the current system, but others do not. The TA vendor will bridge the knowledge gap between the CHCs to ensure that the system is being leveraged effectively to facilitate care transformation and simplify data reporting.

Project Examples

Development and utilization of a CP population health data analytics and visualization system: A CP engages a TA vendor to help develop systems that analyze data from the CP program, claims, and information received from ACOs and other organizations to form customized visuals which can be employed to improve member wellness and care. The TA vendor will help the CP with the design, customization, and automation of their system to minimize the time spent preparing and utilizing visualizations.

Support ACO data exchange with community-based housing services: An ACO works with a TA vendor to implement information exchange with community-based housing non-profit organizations. The ACO has existing relationships with housing organizations and frequently refers members to housing services; however, the ACO does not have processes to share relevant member data with these organizations. The TA project will enable the ACO to seamlessly share relevant information to ensure coordinated, holistic care. This project also addresses Competency Area #1 in that advances the ACO’s ability to address a critical health-related social need on behalf of its members.