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.

ACO Projects

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 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.

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 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.

CP Projects

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.