Innovative Solutions that Transformed Care: The Massachusetts DSRIP Experience
Since November 2017, 16 states have committed with the Centers for Medicare & Medicaid Services (CMS) to transform their Medicaid delivery systems through innovation, redesign, and infrastructure development improve access to behavioral health, and address health-related social needs.
For over 35 years, Advocates for Human Potential, Inc. (AHP) has been improving health and human services systems of care and business operations to help organizations and individuals reach their full potential. AHP has extensive experience in criminal justice and justice-involved populations, from conducting assessments to planning programs, and from implementation to evaluation.
The Massachusetts 1115 waiver for the Delivery System Reform, Innovation and Payment program (DSRIP) established 27 Community Partners (CPs) to collaborate with 17 Accountable Care Organizations (ACOs) to support MassHealth members who presented with complex health, behavioral health and social needs, histories of high utilization of behavioral health services, and patterns of housing instability.
Over five years, Advocates for Human Potential (AHP) provided technical assistance and consulting in 35 contracts with CPs and ACOs as part of the MA DSRIP technical assistance program; a number of providers contracted for subsequent rounds of contracting based on successful interventions.
Individualized Workforce Solutions
For each of the 35 contracts, AHP assembled a team that partnered with program leaders to address their unique challenges. Each intervention addressed key performance metrics in the MassHealth contracts.
Key accomplishments include:
- Improved Community Partner workflows that enhanced member engagement and care coordination
- Expanded coaching skills of supervisors in CP settings
- Established behavioral health providers for patients to access in primary care settings
- Strengthened skills of pediatric care coordinators
- Improved supervision, retention, and effectiveness of care coordinators
- Built CP program dashboards to enhance population health management and demonstrate value to ACOs
- Combined data from Medicaid claims, CP internal processes, and electronic medical records to improve workflows and increase member engagement
Successful Interventions with CPs and ACOs in Massachusetts DSRIP
Developed Care Coordination Core Competencies:
AHP trained care coordination staff from a number of CPs and ACOs to build a workforce with a common set of knowledge, skills, and abilities, critical to their roles in engaging members.
IMPACT: Through AHP’s training, 100 staff acquired competencies in maintaining professional boundaries, effective communication, how to navigate the behavioral health system, and creating linkages with PCPs.
Standardized Care Coordination Processes:
AHP partnered with CPs to assess strengths and gaps in processes and redesigned workflows to support timely outreach, engagement, care plan completion, and follow up.
IMPACT: Staff were trained in a standard uniform process. Program managers improved their ability to
monitor and manage continuity of service delivery and adherence to quality metrics.
Addressed Health-Related Social Needs for Pediatric Populations (Social Drivers of Health):
AHP led the redesign of pediatric care coordination procedures for an ACO aimed at improving health outcomes by addressing social drivers of health and behavioral health.
IMPACT: Pediatric care facilitators were trained in 12 distinct standard work processes promoting overall continuity of patient care across multiple pediatric practice sites.
Created a Data Integration Strategy:
AHP worked with a CP to develop a data integration strategy with data warehouse, analytics, reporting, and business intelligence tools. The result was an interactive dashboard showing history based on member claims combined with current engagement status.
IMPACT: Program managers improved their ability to monitor activities of care coordinators in a timely manner, ensuring member linkage with primary care and following up with members more quickly after ED visits.
Enhanced Integrated Care:
AHP trained a large ACO in Central Massachusetts in adult and pediatric primary care, behavioral health, and substance use services. Services included documenting and standardizing workflows and creating integrated care training materials for patients and staff.
IMPACT: Created structured access for primary care teams to work with behavioral health and SUD services and created informational videos for patients to understand integrated care and for new staff to work in integrated service environments.
Strengthened Workforce Recruitment, Onboarding, and Retention:
AHP assisted several CPs to revise care coordinator job descriptions and advertisements and to develop onboarding manuals, checklists, and other job aids to clarify scope of practice, required competencies, knowledge, skills, and abilities. AHP also helped design career ladders to support the recruitment and retention of staff.
IMPACT: Organizations increased applicant pool for open positions, created a clearer understanding of job expectations, and established new career ladders to support retention.
About Us
Advocates for Human Potential, Inc. (AHP) creates powerful solutions to improve health and human services systems. By partnering with the federal government, states, municipalities, healthcare systems, and nonprofits, we help people experiencing the greatest disadvantages lead full and productive lives. We are national leaders in training and technical assistance, research and evaluation, publishing, and dedicated consulting. On issues from workforce development to mental health, substance use disorders to housing and homelessness, we help our clients enhance behavioral health care through systems change. AHP was founded nearly 40 years ago to develop solutions for some of the biggest social infrastructure challenges across the nation. Our company has offices in metro Boston, Chicago, and Los Angeles. Find out more at www.ahpnet.com.
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