TA Competency Areas outline the key spaces within which ACOs and CPs can continually develop their capabilities in order to improve member experience and health outcomes while lowering total cost of care for MassHealth members.

TA Domains reflect the areas of TA that MassHealth ACOs and CPs identified as TA priority areas during their first year of implementation.

ACOs and CPs identify both the TA Competency Area(s) and the TA Domain associated with a TA project at the time of application.

If you are interested in learning more about a particular project or would like to connect with the ACO or CP to discuss their TA effort, please contact us.

Actuarial and Financial

A TA Vendor is building a centralized data warehouse for a CP that will contain member-level claim and eligibility information across all payers and be the repository for future report building. The end product will be a fully functional SQL data warehouse that will allow the CP to input ongoing claims data files and generate reports. The CP will be able to change inputs and assumptions to understand the impact on claims costs and savings.

An ACO is working with a TA Vendor to overcome challenges accessing claims and financial performance data from its Managed Care Organization (MCO) partner. The TA Vendor is setting up a process and analyzing raw claims data from the MCO as well as from EOHHS; developing a financial performance reporting system; and creating a rising risk registry to refine the ACO’s care management strategy.

A TA Vendor is conducting a fraud, waste, and abuse detection and analysis on an ACO’s 2018 claims data. This analysis will be used to analyze the claims for suspicious patterns and potential erroneous payments.

Care Coordination/Integration

A CP project is linking together and enhancing care management documentation processes and reporting to determine how best to utilize resources to meet care management requirements. The TA Vendor is assisting the CP in developing standard processes for documentation and reporting. Through detailed assessments, the TA Vendor is identifying the CP’s care coordination needs and developing a strategy to implement recommendations and identify measurable metrics aligned with program goals for continuous tracking and improvement.

A TA Vendor is working with a CP to improve its transitions of care program. The TA Vendor is analyzing the processes and workflows involved in effectively exchanging information between the CP and providers in order to coordinate care in a manner that is highly responsive to MassHealth member needs and preferences. The TA Vendor is conducting a focus group with MassHealth members and a literature review of evidence-based practices and will provide the CP with recommendations and improvement plans for various types of transitions of care.

An ACO project is leveraging the expertise of a TA Vendor to improve the alignment and coordination between the ACO’s care delivery sites and Community Partners. The TA Vendor is assessing the challenges, opportunities and processes to achieve alignment, incorporate best practices in the design and implementation of these processes, and facilitate structured conversations to address barriers.

A TA Vendor is working with an ACO to provide guidance on developing strategies to optimize care management impact utilizing a comprehensive team of care managers, social workers, community health workers, population health specialists and peer recovery coaches. The project includes consultation and assessment, data collection and analysis, and training on best and evidence-based practices, including Motivational Interviewing, and treatment for substance use disorders, and recovery pathways.

A TA Vendor is working with an ACO to develop a substance use disorder (SUD) referral network to complete the ACO’s SUD continuum of care to include all SUD inpatient, residential, and outpatient services covered by MassHealth.

A TA project will provide resources and training to support an ACO’s diverse workforce as they work with individuals who screen positive for housing instability. This population includes members who screen positive for unsafe or unhealthy housing conditions, a need for reasonable accommodation in housing, members threatened with eviction due to alleged non-payment of rent or lease or shelter rule violations, or members at risk of utility service shut-off.

An ACO is working with a TA Vendor to develop and deliver a comprehensive, standardized training program for the individuals in the integrated behavioral health teams (i.e., integrated behavioral health providers and psychiatric prescribers) and in the integrated substance use services teams (i.e., Substance Use Nurse Specialists, Licensed Alcohol and Drug Counselors, and primary care provider Medication-Assisted Treatment prescribers). The integrated behavioral health and substance use services teams at the ACO are among the most important parts of its new care model, and comprehensive and consistent training of these teams is essential to its success.

A TA Vendor is assisting an ACO with the creation and adoption of a stratification tool to assess discharged patients for readmission risk and enroll high-risk patients into a Transition of Care (TOC) care management program. The TA Vendor will also assess and make recommendations around reporting on care management activities to determine how best to utilize resources to meet care management program goals and stratify discharged patients to reduce readmissions.

An ACO project is focusing on enhancing care management documentation processes and reporting to determine how best to utilize resources to meet care management program goals. The TA Vendor is assisting the ACO in developing standard processes for documentation and reporting. Through detailed assessments, the TA Vendor is identifying the ACO’s opportunities for standardization across health centers around documentation to pull consistent data and metrics on care management activities.

A TA Vendor is developing a comprehensive evaluation of current care delivery, care management and care coordination processes and programs, and associated financial incentive structures across an ACO’s delivery system. The evaluation will identify strengths, gaps, and performance improvement opportunities. Based upon the evaluation findings and recommendations, the TA Vendor will collaborate with the ACO to develop a detailed “Redesign Road Map.” This will assist the ACO to prioritize and execute the Redesign Road Map initiatives such as care delivery, financial, and care management and care coordination to achieve more integrated, effective, and efficient care delivery and care management across their delivery system.

Community-Based Care and Social Determinants of Health

A TA Vendor is providing training for Community Health Workers, patient navigators or other staff involved in community outreach and meeting resource needs for patients at an ACO. The training will include a webinar series focusing on an overview of social determinants of health and a series of in-person trainings related to screening for social service needs, referral to services, and the essential interpersonal skills needed when working with individuals and families to meet agreed upon goals.

Consumer Engagement

A TA Vendor is developing a series of videos for an ACO on a variety of topics related to population health management. The TA Vendor will conduct select interviews with ACO administrators, providers, staff, community partners, and patients to collect stories and points of view and develop one longer (~20 minute) video that will be broken up into 3-5 short, impactful videos.

An ACO is working with a TA Vendor on a research project to focus on its critical populations such as Latino (Spanish-speaking) and Brazilian (Portuguese-speaking) MassHealth members who are eligible for services at the ACO’s various locations. The project will help the ACO better understand some of the health barriers these population groups are facing.

An ACO is routinely screening its patients for social determinants of health needs. A TA Vendor is facilitating focus groups with the ACO’s MassHealth members to learn more about their experience with social needs in general, as well as their expectations surrounding the role of primary care in addressing social needs.

A CP project aims to strengthen its capacity to connect with vulnerable, hard-to-reach enrollees who are often unaware of – or unwilling or unable to take advantage of – the significant LTSS benefits offered by their ACO. The CP is working with a TA Vendor to incorporate additional networking techniques and approaches into existing member outreach efforts that focus on creating new channels for effective, comprehensive, and multicultural marketing and engagement strategies. These strategies will enhance the CP’s abilities to deliver services and supports to many of the at-risk individuals identified either by MassHealth or partner ACOs.

Flexible Services

An ACO is collaborating with a TA Vendor to build a framework for the flexible services program and identify and build relationships with social service organizations. The integration between social service and community-based organizations and the ACO’s health centers’ primary care teams will lead to the improvement of member health outcomes and quality of care, and increased collaboration to address health-related social needs.

An ACO project is aimed at designing the housing domain of the Flexible Services Program. The TA Vendor is researching current best practices and evidence-based interventions across the continuum of housing supports in Massachusetts and nationally in alignment with Flexible Service Program guidelines. The TA Vendor is also conducting interviews with key stakeholders at the ACO to understand referral resource experiences, needs of high-risk members, and experiences with referrals and also speaking with potential housing service providers whose services align with identified needs and evidence-based practices. Finally, the TA Vendor is supporting the ACO’s central leadership and key stakeholders with designing the implementation for the housing domain of its Flexible Services Program.

A TA Vendor is collaborating with an ACO to develop high-level recommendations for a Flexible Services pilot program. This includes a program description and operational and financial projections to support their decision-making on what a Flexible Services model could look like given the community needs, the needs of the target population, and strategic goals of the organization.

An ACO project is focusing on enhancing screening and identification of patients with food and housing insecurities to best utilize Flexible Services Program (FSP) resources to meet care management program goals. Through this project, the ACO aims to discern populations that may qualify for the FSP based on diagnoses, develop priorities for its use of the FSP on behalf of members (e.g., housing instability, food insecurity, or a combination of both), and receive recommendations for potential community-based organizations that might successfully meet member needs through the FSP.

Health Information Technology / Health Information Exchange

An ACO is receiving TA Vendor services to complete the implementation of the claims and electronic medical records (EMR) analytics component of their population management platform. The TA Vendor is providing project management and support for validation, standardization, and ongoing maintenance documentation, and user training before launching the analytics component.

An ACO has engaged a TA Vendor to provide support for the development and management of its Flexible Services Program (FSP). The TA project will include support in operationalizing the FSP guidance, mapping current and future processes, and recommending a technology strategy.

An ACO project is focused on enhancing the care provided to its patients through expanding and optimizing the use of a clinical communication software application’s texting function. The TA Vendor will conduct an assessment to review workflows, understand existing communication patterns, and identify opportunities, successes, issues, and barriers through stakeholder interviews. The TA Vendor and ACO will develop a community deployment plan to both reeducate current users and engage new users with the secure messaging capabilities of the software program.

A TA Vendor will assist an ACO with a detailed analysis of the current database design, data input and export files, and reporting capabilities to ensure compliance with all program requirements, and population health reporting goals. Through detailed assessments, the TA Vendor will identify the ACO’s care coordination needs and develop a strategy to implement recommendations and identify measurable metrics aligned with program goals for continuous tracking and improvement. In addition, the TA Vendor will assist in developing standard processes for documentation of required data elements, and assist in creating and implementing their reporting process.

A TA Vendor is developing and customizing a solution for a CP that will provide query capabilities to support review, integration, analysis, and trending of data populated by identified data sources. The TA Vendor is developing and customizing dashboards and actionable reports that allow the CP to efficiently use care team resources in reviewing data necessary to develop real-time, meaningful, and streamlined service plans for members.

A CP is working with a TA Vendor to assess the current state of its care coordination software. The TA Vendor is identifying existing functionality gaps and user pain points; categorizing issues by root cause; determining the necessary steps, feasibility, and level of effort to resolve issues; and creating a detailed action plan for the ACO to follow.

A TA Vendor is assisting a CP with the planning and implementation of a new long term services and supports and care coordination data platform. To ensure an effective transition to the new platform, the TA project will include a detailed implementation plan that ensures comprehensive training, develops robust reporting capabilities, and facilitates communication between CPs and ACOs. The TA Vendor is conducting key activities of the implementation such as workflow analysis, system build, data migration, acceptance testing, training, go-live support planning, and is creating a plan for receiving ongoing support through the technology platform when the TA project concludes.

An ACO project will utilize TA Vendor services to assist with reporting on clinical quality measures. The TA Vendor will facilitate gather discrete clinical data to inform the clinical quality measures, as part of the mandated reporting process to EOHHS.

A TA Vendor is providing a comprehensive assessment of the software a CP is utilizing to support care coordination and delivery of social and medical services to its population. The TA Vendor will identify existing functionality gaps and user pain points with the current system; categorize issues by root cause; determine the necessary steps, feasibility, and level of effort to resolve issues; and create a detailed action plan for the CP to follow. The project will help address current gaps in technology that prevent seamless patient care work flows and integration with MassHealth ACOs.

A CP project is leveraging a technology platform and its primary care electronic health record to share data and increase efficiencies in care coordination between CP and primary care staff. Specifically, a TA vendor will investigate how shared data would improve coordination between CP and primary care staff, develop tools for efficiently sharing data, and train staff on new processes.

An ACO project is working to eliminate the manual burden of printing, faxing, and scanning the Care Plans and Comprehensive Assessments (CPCAs) at the health centers and with its CPs. This electronic exchange will leverage the HIE connections forming a central hub. The HIE connection will lay the foundation for CPCAs to be stored as discrete data and available for reporting and updating as plans are renewed or modified over time. The initiative will also begin to phase out the transactional logs that health center staff maintain in spreadsheets for Managed Care Organization and EOHHS reporting.

Performance Improvement

A TA Vendor worked with an ACO to develop and facilitate a full-day retreat for the ACO’s Board of Directors. The retreat focused on execution success for the most critical, strategic priorities facing health centers in 2019.

A CP is receiving support from a TA Vendor to operationalize each mandated Behavioral Health (BH) and Long Term Services and Supports (LTSS) quality measure for CPs. Through this project, the CP will work to improve approaches and interventions that enrollment specialists and the care team can employ to improve member engagement. It will also develop effective workflows for collecting and reporting on quality data and communicating and exchanging data with enrollees, primary care providers, and ACOs. The project will assure the accuracy of reports and provide a framework for care coordination activities in order to meet complex care needs and preferences of members and contribute to the CP’s long-term financial sustainability goals.

Population Health Management

An ACO is working with a TA Vendor to improve the accuracy of claims data and risk scores for its patients to support a variety of population analyses including risk stratification, intervention planning and implementation, and financial and programmatic evaluation. The ACO also plans to apply patient data and qualitative insights toward design, implementation, evaluation, and refinement of risk stratification models that may be unique to the pediatric patient population.

A TA Vendor is supporting an ACO through advanced data analytics capabilities. This project will drive targeted and effective clinical interventions focused on addressing issues such as transportation, enrollment and coverage, housing, and nutrition/food security. The TA Vendor will utilize external datasets and data science to understand social determinants of health needs and drive targeted analytical interventions in conjunction with current or future clinical programs. The project will also identify and plan for Flexible Services Program design and population identification.

A TA Vendor is working with an ACO to develop new strategies for engaging MassHealth members. The TA Vendor will utilize a variety of tools and databases to access supplemental contact information, location data, and member relationships and other non-clinical factors beyond information gleaned from a claim or typical encounter. This new source of data will allow the ACO to analyze and stratify its members and also determine the range of appropriate interventions, programs, and resources to address their unique needs.

A TA Vendor is assisting an ACO in conducting electronic health record chart reviews for missing or updated data for each patient as needed from the samples provided in order to complete data measurement and reporting requirements.

A TA Vendor is providing social determinants of health data about a CP’s attributed MassHealth members to the CP’s current operational programs, teams, and technology tools. This new source of data intelligence will allow the CP to review opportunities for collaboration with ACO partners; lower the total medical expense of the population over time; further engage hard-to-reach members; and decrease quality gaps in care. Additionally, the project aims to increase the ability of care managers, clinicians, and peer coaches to drive effective interventions and inform program design including strategies for engagement and intervention to optimize member experience.

A CP is collaborating with a TA Vendor on a project collecting and assimilating data from various sources with the aim of transforming the data into meaningful and actionable information to support population health management.

Two CP organizations are working with a TA Vendor to deploy a data management and analytics environment to support reporting and analytics using internally and externally sourced healthcare claims, care coordination, and related data. The TA Vendor will assist the CPs in developing the high level design of the data management and analytics solution and a plan to build and deploy this solution. The TA Vendor will also analyze the CPs’ analytics requirements, assess their current data, organization and technology, and provide recommendations for a future state data and analytics solution architecture that aligns to the CPs business goals and requirements. The TA Vendor will also provide the CPs with a set of recommended steps to implement the solution.

A TA Vendor is working with an ACO to address social determinants of health (SDOH) to improve care for its communities in a fiscally responsible manner. This project is allowing the ACO to engage hard-to-reach members, decrease quality gaps in care, and improve overall health by increasing the ability of care managers, clinicians, and peer coaches to drive effective interventions.

A TA Vendor is working with a CP to design a tool that can be used to predict outcomes for LTSS CP members and to generate the information needed to identify best practices in meeting the person-centered needs of members with LTSS needs. This tool will enhance the CP’s capacity to: drive meaningful improvements in health and well-being for LTSS CP members; advance integration in health care delivery; address a gap in the field of predictive modeling for persons with LTSS needs; and, support the sustainability of CPs by demonstrating the value of providing care coordination to outcomes.

Workforce

A TA Vendor is working with an ACO to deliver a Community Health Worker (CHW) Core Competency training aligned with the standards set by the Massachusetts Board of Certification of CHWs. The CHWs at the ACO will participate in sessions aimed at helping the organization achieve the cost, quality, and health outcome goals of health reform, while reducing disparities in healthcare and outcomes. Training series content includes culturally responsive care, professional boundaries, group and individual engagement strategies, assessments, communication skills documentation, system navigation, advocacy, motivational interviewing, and public health concepts.

A TA Vendor is partnering with an ACO to review current practices, make strategic recommendations, and conduct social determinants of health training programs. This includes evaluating workflow processes, current job descriptions, system capabilities and measurement frameworks and introducing evidence-based and community informed practices to better meet their patients’ health-related social needs.

A TA Vendor is working with two CPs on a workforce enhancement project. The TA Vendor is assessing the clinical work processes and procedures, developing job duties and identifying professional development needs among clinical care managers, supervisors, enrollment specialists and care coordinators at the CPs. The TA Vendor is also developing a workforce development plan to support staff and supervisors to create a more collaborative and efficient work environment.

An ACO project aims to train medical assistants (MAs) in several health centers on the topic of “Inter-professional Team-Based Care.” The training initiative will increase the insights and capabilities of MAs in population health areas such as addressing quality gaps, and in fundamental skills like communication and teamwork. The training includes a mix of in-person, live video conference, and recorded sessions to meet the varied needs and capabilities of health centers. Participating health centers are also identifying two leaders to participate in bi-monthly or monthly meetings co-facilitated by the TA Vendor and ACO to ensure the initiative is embedded within overall strategy for team-based care improvement.