The TA project examples below include a variety of TA projects ACOs and CPs are conducting under the MA DSRIP TA Program. These examples aim to offer inspiration to ACOs and CPs as they consider how to use their TA Card funds.
For more information, contact MA_DSRIP_TA@abtassoc.com.
Actuarial and Financial
- CP Issue: A CP wants to maintain financial stability and continue its Behavioral Health CP Program after DSRIP funding ends.
- TA Solution: A TA Vendor is developing an analytic framework that helps the CP understand the path to financial sustainability. The TA Vendor is using models and projections to simulate paths forward to achieve financial stability for the continuation of the CP’s Behavioral Health CP Program after the end of DSRIP funding in 2022. The TA Vendor will interview CP staff to discuss program operations, models of care, desired program outcomes and expenses, and staffing models. They will incorporate this information into the final product: an excel-based model the CP can manipulate to test different spending and saving plans for financial growth and stability.
- ACO Issue: An ACO experiences challenges with accessing claims and financial performance data from its Managed Care Organization (MCO) partner.
- TA Solution: The TA Vendor is setting up a process for and analyzing raw claims data from the MCO as well as from the Massachusetts Executive Office of Health and Human Services; developing a financial performance reporting system; and creating a rising risk registry to refine the ACO’s care management strategy.
- ACO Issue: An ACO wants to better understand its financial outlook for the upcoming year.
- TA Solution: A TA Vendor is working with the ACO by utilizing the 2021 rate package from MassHealth, reviewing all relevant materials, and constructing a financial projection model. The modeling will help the ACO target performance improvement levels needed to achieve its financial goals.
- CP Issue: A CP needs a tool to guide appropriate population health interventions.
- TA Solution: A TA Vendor is developing a robust predictive modeling tool to support LTSS CP enrollee risk stratification and care coordination efforts, guide appropriate population health interventions, and influence future value-based reimbursement arrangements. The predictive model will leverage MassHealth data, including claims data and member demographic information, and LTSS assessment data collected by the CP.
- ACO Issue: An ACO’s Community Health Workers use a manual process to identify and prioritize patients for outreach. This uses .5 FTEs per health center.
- TA Solution: The TA Vendor is creating automated weekly updates to the patient registry, with tasks and deadlines in the management system. Automating these processes frees up staff to spend more time on patient care.
- CP Issue: A CP wants to improve its program infrastructure and update its model of care to meet MassHealth contract requirements, member needs, and ACO needs.
- TA Solution: A TA Vendor is working with the CP, reviewing the current model of care, including staffing and roles, key processes and hand-offs, and opportunities to better integrate functions within the team. They are also reviewing CP and ACO behavioral health contract requirements and the current model of care, with detailed process maps and descriptive information. The TA Vendor will then make recommendations to improve program infrastructure and update the model of care.
- CP Challenge: A CP wants to identify priorities and strategic opportunities for promoting the sustainability of the program and its relationships with ACO partners.
- TA Solution: A TA Vendor is gathering input from the CP, its key stakeholders, and ACO partners on the current state of the CP program and ACO/CP integration initiatives to inform future direction and sustainable relationships with its ACO partners.
Community-Based Care and Social Determinants of Health
- ACO Issue: A group of ACOs want to improve their understanding of patients’ social needs and practices to address them.
- TA Solution: A TA Vendor is working with the ACOs to build staff fluency of patient social needs and implementing workflows to address them. This includes approaches for screening and follow up; developing workflows and infrastructure; engaging external stakeholders; identifying best practices for following up on patients’ needs; and sharing and analyzing aggregate social needs screening data.
- CP Issue: A CP wants to understand and track whether all populations in their program are benefiting equally from their work so that they can address disparities.
- TA Solution: A TA Vendor is conducting an environmental scan and developing an equity evaluation and monitoring plan (including an equity framework, analytic approaches, and instrument development or enhancement). They will also deliver recommendations for infrastructure changes and communication with staff around clinical equity.
- ACO issue: An ACO is launching a new housing initiative for persons experiencing homelessness or at risk of homelessness and avoidable care utilization. The ACO has established partnerships with local housing authorities to optimize patient access to scarce housing resources. Their staff want to be able to identify and help with legal risks or barriers their members may have in accessing housing.
- TA Solution: The TA Vendor is training the ACO and its care management staff to recognize legal risks like criminal justice system involvement, eviction history, or reasonable accommodation requests for landlords, with remedies and problem-solving strategies they can deploy with patients.
- ACO Issue: An ACO wants their Community Health Workers and Patient Navigators to better identify their patients’ social determinants of health needs.
- TA Solution: A TA Vendor is providing training for Community Health Workers, patient navigators or other staff involved in community outreach for patients. The training includes a webinar series focusing on social determinants of health with a series of in-person trainings on screening for social service needs, referral to services, and the essential interpersonal skills needed for working with individuals and families.
- ACO Issue: An ACO’s critical population members include Latino (Spanish-speaking) and Brazilian (Portuguese-speaking) MassHealth members who are eligible for services but do not receive them.
- TA Solution: A TA Vendor is working with the ACO to research the health barriers these populations experience, help the ACO address the barriers, and get individuals the care they need.
- CP Issue: A CP wants to strengthen its capacity to connect with vulnerable, hard-to-reach enrollees who are often unaware of, unwilling or unable to take advantage of the significant LTSS benefits their ACO offers.
- TA Solution: A TA Vendor is working with the CP to incorporate additional networking techniques and approaches into existing member outreach efforts. These techniques will create new channels for effective, comprehensive, multicultural marketing and engagement strategies. The project aims to help the CP deliver services and supports to at-risk individuals identified by MassHealth or partner ACOs.
- ACO Challenge: An ACO wants to take steps to improve patient outcomes through patient education and engagement.
- TA Solution: A TA Vendor is developing patient education materials that address chronic conditions like diabetes, heart failure, and chronic obstructive pulmonary disease. The project closely links patient education to digital health efforts that seek to create a broader framework for patient engagement.
- CP Challenge: A CP wants to improve staff skills in enrollee outreach and engagement.
- TA Solution: A TA Vendor is conducting focus groups with CP staff to learn about the specific challenges front-line care coordinators face in sustaining ongoing engagement with enrollees, including geography-specific challenges. The information from focus groups will be used to inform training. The TA Vendor will develop and deliver training to care coordinators and nurse care management staff on strategies and activities to increase and sustain member engagement.
- ACO Issue: An ACO wants to enhance identification of patients with food and housing insecurities to optimize their use of Flexible Services Program resources.
- TA Solution: A TA Vendor is working with the ACO to help identify populations that may qualify for the Flexible Services Program based on diagnoses. They are developing priorities for members’ use of the Flexible Services Program (e.g., housing instability, food insecurity, or a combination of both), and providing recommendations for potential community-based organizations that can meet member needs.
Health Information Technology/Health Information Exchange
- ACO Issue: An ACO needs an efficient system to authorize, track, and reconcile services delivered by social service organizations.
- TA Solution: A TA Vendor is providing project management support for the ACO’s implementation of a Flexible Services software platform. This platform helps care teams communicate directly and collaborate with social service organizations on member outreach, engagement, planning, and follow up activities. Partnering social service organizations can use the Flexible Services system to track their own referrals, manage their workloads, and communicate with care teams.
- CP Issue: A CP wants their care team to have real-time, meaningful dashboard reports for their members and population so they can manage their cases and members most efficiently.
- TA Solution: A TA Vendor is working with a CP to develop and implement a data integration and online reporting solution. The TA Vendor is customizing a solution for the CP with query capabilities that support review, integration, analysis, and trending of data populated by data sources like MassHealth Referral Data, Assignment Files, Assessment Data, and Claims Data. The TA Vendor is developing and integrating the online reporting environment with the CP’s case management system. This integration will deliver population and member-specific dashboard reports that facilitate development of real-time, meaningful, and streamlined service plans that avoid duplication of services, address service gaps, and track interventions.
- CP Challenge: A CP wants to address gaps in technology that prevent seamless patient care workflows and integration with MassHealth ACOs.
- TA Solution: 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 is identifying existing functionality gaps and user pain points in the current system; 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.
- ACO Challenge: An ACO wants to enhance the care provided to its patients by expanding and optimizing the use of a clinical communication software application’s texting function.
- TA Solution: A TA Vendor is conducting stakeholder interviews to review workflows and communication patterns, and identify opportunities, successes, issues, and barriers. The TA Vendor and ACO will develop a community deployment plan to reeducate users and engage new users with the secure messaging capabilities of the software program.
- CP Issue: A CP wants to improve outreach activities to optimize billable per member/per month payments, rates of engagement, and performance on quality measures.
- TA Solution: A TA Vendor is analyzing the CP program’s workflow, processes, and staffing around member engagement. The TA Vendor is conducting a comparison of current team processes against best practices, and identifying the financial and organizational impact of recommended changes. They are also making recommendations for revised workflows, processes, and staffing models to enhance outreach activities.
- ACO Issue: An ACO wants to identify deficiencies in the screening and referral process for identifying social determinants of health so they can better meet the needs of their members.
- TA Solution: A TA Vendor is evaluating the ACO’s process of screening individuals for social determinants of health and the actions physicians, care teams, and community-based or social service organizations take based on the screening and referral data. The TA Vendor is receiving 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.
- CP Issue: A CP wants to optimize its clinical capacities and strengthen the ability to engage members with a substance use disorder.
- TA Solution: A TA Vendor is conducting an analysis for strategic planning of a CP’s internal and external (primary ACO’s) workflows and processes for the initial assignment of members with a substance use disorder. The TA Vendor is making recommendations for revised workflows and processes to optimize the CP’s clinical capacities and strengthen the ability to engage members with a substance use disorder, and is facilitating a training for the CP and ACO on the revised workflows. In addition, the TA Vendor is providing strategic planning and recommendations for improved workflows on the two shared BHCP/ACO Emergency Department-related quality measures to achieve improved performance and health outcomes for shared members. Finally, the TA Vendor is facilitating a two-month “proof of concept” project with the primary ACO to demonstrate the effectiveness of the revised workflows on the shared Emergency Department quality measures.
- ACO Challenge: An ACO wants to improve care for multi-visit patients. This will help them achieve important clinical, operational and organizational capability goals.
- TA Solution: A TA Vendor is utilizing a rapid-cycle continuous improvement methodology to inform and implement continuous improvement efforts. Their goals include: understanding the drivers of utilization of multi-visit patients, and developing the interdisciplinary cross-setting team based cultures, norms, processes and workflows to support improved service delivery over time.
Population Health Management
- CP Issue: A CP wants to analyze their population’s characteristics and explore the feasibility of integrating additional criminal justice data and data from affiliated partners’ electronic health records so they can strengthen their value, efficiency and effectiveness.
- TA Solution: A TA Vendor is leveraging existing quantitative and qualitative data including electronic health record data, local homeless management information system data, social needs screening data, and claims from MassHealth and ACOs (medical, behavioral, and social) to better analyze and report on the CP’s population characteristics.
- ACO Issue: An ACO wants to deploy interventions to address social determinants of health in their members and identify non-clinical issues that may predict future high-cost utilization. They also need measures to evaluate and review their performance.
- TA Solution: A TA Vendor is working with the ACO to identify new opportunities to engage members and deploy interventions to address social determinants of health. This TA project is surfacing the social determinant acuity of the entire population and identifying patients who are candidates for a complex care management program. The TA Vendor is also developing a database of social determinant factors by member, analyzing and stratifying membership based on utilization, identifying non-clinical indicators that may be predictive of future high-cost utilization, and developing measures to evaluate this work and review performance.
- ACO Issue: An ACO wants to improve visibility of health-related social needs and to identify and align the care being delivered to patients to address these needs.
- TA Solution: A TA Vendor is working 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 work streams to increase revenue and support medical management for the most vulnerable members facing housing instability.
- CP Issue: A CP wants to collect, integrate, analyze, and report data from MassHealth partners and the electronic health record platform more efficiently and effectively across the organization.
- TA Solution: A TA Vendor is developing and deploying a comprehensive training program that addresses the unique needs of CP staff at different levels of the organization. The trainings will be based on population health management principles. The project will also engage CP leadership to more effectively collect and use patient health data for population health management.
- CP Issue: CP care coordinators need training on a variety of health topics and best practices.
- TA Solution: A TA Vendor is delivering special topic trainings for CP care coordinators on diabetes, cancer, mental illness, and addiction. The trainings include modules on culturally responsive care with a focus on cross-cultural communication to specific populations served by the CP. It also includes practice-based motivational interviewing that builds on the community health worker core competency course.
- ACO Issue: An ACO’s pediatric care facilitator (PCF) workforce is comprised of non-licensed staff who help families access services addressing social determinants of health and behavioral health. The PCF workforce need professional development to better support pediatricians’ efforts to address the needs of their patients.
- TA Solution: A TA Vendor is helping the ACO redesign procedures, train staff in competencies, and train supervisors to support PCFs professional development. Training topics include: practical applications of motivational interviewing; persistent person-centered engagement; coordination and collaboration; understanding family dynamics and social needs; addressing familial and systemic barriers to care; professional boundaries; and understanding one’s role relative to high-risk behavioral health issues (e.g. abuse and neglect, domestic violence, and psychiatric crisis).
- CP Issue: Two CPs want to create more collaborative and efficient clinical work processes and procedures.
- TA Solution: A 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. They are also developing a workforce development plan to support staff and supervisors in creating a more collaborative and efficient work environment.
- ACO Issue: An ACO wants to improve engagement of families of children with special health care needs to improve their access to services.
- TA Solution: A TA Vendor is training Community Health Workers to engage with the families of Children and Youth with Special Health Care Needs who are enrolled in the ACO. This will help the Community Health Workers and the ACO have meaningful interactions with families as they navigate complex health and education systems. The training involves developing shared planning and prioritizing with families, and emphasizes the ways that Community Health Workers can help families better access services.