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.
If you see a TA Project of interest and would like to see the vendors working in that TA Domain, click the icon beside the project to view the Vendor Catalog.
A TA Vendor is providing analysis and recommendations on potential strategies to reduce avoidable readmissions and emergency department utilization for ACO members. The TA Vendor is also advising the ACO on how to strengthen the systems, services, and processes currently in place, with a focus on engaging interdisciplinary and cross-setting care teams to understand drivers of utilization for multiple visit patients of the hospital inpatient and emergency room settings. The TA vendor then teaches the teams a common language and framework for developing new processes for care delivery to meet the needs of this population and improve outcomes.
A TA Vendor is working with an ACO on a project to understand the opportunities to engage members and accurately identify risk – beyond the traditional information gained from a claim or typical encounter. In addition, the TA Vendor is evaluating additional work streams to increase revenue and support medical management for the most vulnerable members facing housing instability. The project is aiming to improve visibility of social determinant acuities and identify and align the care being delivered to these vulnerable members.
An ACO project is reviewing existing competencies, work standards, and best practices for roles such as patient navigators and other non-clinical care coordinators nationally and in Massachusetts. The project also includes small focus groups, interviews, and brief online surveys to understand the current job activities and the knowledge, skills, and competencies required. The ACO is using this information to codify specific job roles for the various unlicensed paraprofessionals that are facilitating and coordinating medical, social, behavioral health, and other needs and working alongside medical providers, social workers, care managers and coordinators, and administrative and office staff in the ACO.
A TA Vendor is utilizing large data sets as the basis for predictive analytics to provide an ACO with insights that drive timely and targeted interventions to address the social determinants of health of its members. The analysis will help the ACO measure the social determinant acuity of its entire population; understand the engagement and contact challenges of the membership; and align resources to meet member needs. The TA Vendor is also stratifying the membership based on opportunity and rating classes; identifying non-clinical barriers to care; determining an appropriate intervention program; and measuring the value in a scaled solution across various ACO programs.
An ACO project is focused on building and sustaining effective partnerships with CPs in order to improve care coordination and integrated care delivery for members with complex health care needs. Through this project, the ACO will assess the current operations of collaboration by gathering information and data on workflows and processes, and input from key stakeholders. Upon an evaluation of the current state, the ACO will be able to review and identify opportunities for improvement and enhancement of CP operations, specifically to improve communication about members referred to the CP program and integration of BH and LTSS services managed by CPs back into the primary care practice.
An ACO project is focused on the priority area of reducing emergency department utilization and preventable hospital admissions among high-risk patients with behavioral health conditions. The project is planning an appropriate array of services for these populations and making recommendations to comprehensively address their needs.
A TA Vendor is assisting an ACO with the development and documentation of how to deliver integrated behavioral health services in family practice and pediatric care settings, integrating substance use disorder clinicians further into primary care practices, as well as developing a comprehensive, standardized training program for the staff in the integrated behavioral health teams. In addition, the TA Vendor is creating processes to support the integration of the behavioral health/mental health and substance use disorder teams, including assuring that these teams are properly and consistently trained.
An ACO is evaluating its process of screening individuals for social determinants of health and the actions taken by physicians, care teams, and community-based or social service organizations based on information collected during the screening and referral processes. The TA Vendor will seek input from physicians, care teams, community health workers, and others to better understand the current process, obtain feedback, and assess the goals and expectations for screening, referral, and follow-up with patients. This analysis will help to uncover deficiencies in the process flow and identify opportunities for optimization.
A TA Vendor is working with a group of ACOs to build fluency around patient social needs. The project is focusing on a variety of topics including identifying approaches for screening and following up on the social needs of patients; developing associated workflows and infrastructure; engaging external stakeholders and identifying best practices for following up on needs; and sharing and analyzing aggregate social needs screening data.
An ACO is engaging a TA Vendor to assist with an evaluation of all current systems and processes that support the capture of clinical data. Based on the findings from the analysis, the TA Vendor is providing actionable recommendations for improvements to processes as well as a recommended report set to be used to monitor the ongoing quality and complete capture of clinical data.
An ACO is partnering with a TA Vendor to conduct a housing market analysis to identify key housing units and potential future partners. The TA project is aiming to advance the ACO’s continued focus on assisting its members with coordinated care and/or complex care management to obtain access to community resources to prevent illness and improve outcomes. The project will also allow the ACO to begin designing future interventions to address housing insecure patients.
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.
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 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 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.
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 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.
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.
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 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.
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 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 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.
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.
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.
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.
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 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 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.
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.
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.
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 connection 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.
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.
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 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 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 delivering an 84 hour Community Health Worker (CHW) Core Competency Training aligned with the standards set forth by the Massachusetts Board of Certification of CHWs. Training 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 conducting a Learning and Needs Resource Assessment and developing and implementing a training curriculum to improve the competencies and skills of the care coordinator workforce at a CP. The trainings for the care coordinators aim to improve competencies and skills to best impact quality, patient and provider experience, and cost.
A TA Vendor is working with a CP to conduct a review of the current model of care, including, but not limited to, staffing and roles, key processes and hand-offs, and opportunities to better integrate functions within the team. The TA project includes a review of behavioral health CP and ACO contract requirements; current model of care (detailed process maps and descriptive information) and job descriptions and staff roles. The TA Vendor is making recommendations on how to improve program infrastructure and update the model of care to reflect assigned and engaged member needs, MassHealth contract requirements, and ACO needs.
A TA Vendor is working with the leadership team at a CP. This support will focus on prioritizing objectives, developing a realistic and appropriate deliverables-based plan and timeline, and implementing targeted strategies and tools to effectively communicate and track progress of the management team staff to achieve results needed for ongoing sustainability of various CP programs.
A CP TA project is focusing on improving its processes in order to efficiently identify, outreach, engage, and deliver behavioral health services to assigned individuals. For this TA project, the TA Vendor is mapping out all aspects of the process – from the point that a referral file drops through the eligibility, outreach, assessment, care plan development, participation agreement signature process, to billing processes. The maps include the number of individual members who have completed each process, and identify specific reasons that an eligible individual did not advance through the complete process. The results are assisting the CP with understanding opportunities to improve or re-design processes.
A CP is working with a TA Vendor to develop a business and clinical model that is sustainable and viable long into the future, especially as it relates to growth in the ACO and hospital market. Essential to this effort is increasing the CP’s ability to collect, integrate, analyze, and report data that will ensure the CP can independently and continuously improve in quality, outcomes, and total cost of care. The TA Vendor is also assisting the CP with applying the findings from the TA project to enhance its program and reputation and be recognized as a valuable and trusted partner to the ACOs.
Two CPs are working with a TA Vendor on a project with the goal of developing a health informatics platform to integrate enrollment data with historical claims data, append additional individuals and claims as they are delivered, conduct in-depth quality and consistency checks on the data, produce regular defined reports, and develop a user-friendly tool for staff to conduct discrete analyses and reports.
A CP project is aiming to improve and enhance the level of outreach and engagement throughout the communities it supports. A TA Vendor is conducting an evaluation and assessment of current processes, identifying opportunities for improvements, and integrating best practices into outreach and engagement strategies.
A TA Vendor is working with a CP to analyze the claims dataset provided by MassHealth, and stratify the data to establish high, moderate, and low risk divisions or sub-groups of members according to utilization, diagnosis, and other characteristics. The TA Vendor is merging the claims data with the electronic medical records and evaluating each stratum to identify commonalities, opportunities to improve, and appropriate evidence-based practices or clinical pathways for each. The TA project is helping the CP plan for the future by identifying gaps in the system of care corresponding to strata and providing data to support discussions with ACOs on the potential for shared risk.
A CP is working with a TA Vendor to put systems in place to manage and optimize the large volume of data the CP is receiving from ACOs about its members. Through the TA project the team will seek to leverage existing software programs and processes that monitor quality and productivity to create a data analysis toolset that supports utilization of data to identify trends and patterns in performance. The TA project will also seek to streamline operations, improve efficiencies and integrate CP performance of qualifying activities with billing and accounting functions creating a seamless glide path from service delivery to billing and reconciliation of payments.
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.
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.
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 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.
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.
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 CP to follow.
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 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.
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 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.
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.
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.
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 ability 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.