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.
ACO Projects
A TA Vendor is delivering an 80-hour Community Health Worker (CHW) Core Competency Training for an ACO that is aligned with the standards set forth by the Massachusetts Board of Certification of CHWs. The ACO’s CHWs will participate in 12 full-day sessions aimed at helping the organization achieve the cost, quality, and health outcome goals of health reform, while reducing disparities in health care and outcomes. Content of the series includes culturally responsive care, professional boundaries, group and individual engagement strategies, assessments, communication skills documentation, system navigation, advocacy, motivational interviewing, and public health concepts. The goal is for the ACO’s CHWs to use their new skills to perform their roles more effectively which will also free up clinicians to focus more on their clinical work. (Added March 2022)
A TA Vendor is providing project management and support to help two ACOs produce the MassHealth deliverables effectively (i.e., timely and accurately) and efficiently (i.e., with minimal negative impact on resources). This involves identifying the resources needed, establishing roles and responsibilities, managing timelines, filling gaps, gathering data and information, populating required templates, ensuring compliance with MassHealth requirements, ensuring strategic discussions are well-informed and involve the appropriate staff, and ensuring timely and accurate completion of deliverables.
This TA Project aims to improve capacity, performance, and sustainability of the ACOs by optimizing decision-making regarding investments and strategy, identifying required staffing, establishing team roles and responsibilities, and implementing repeatable processes. The workflows, processes, and tools that the TA Vendor develops on behalf of the ACOs will also help strengthen systems by establishing a methodology that can be used for future deliverables. (Added March 2022)
A TA Vendor is working with an ACO to conduct a Community Oral Health Assessment. The project is focused on including oral health with existing regional wellbeing assessment processes and developing a stand alone oral health assessment. During this assessment process, the TA Vendor is conducting a landscape analysis, collecting qualitative data through key informant interviews and focus groups, administering a community survey, developing draft and final assessment reports and an accompanying slide deck and a case study/playbook for replication. They are also providing support for the development of an advisory board. (Added March 2022)
A TA Vendor is helping an ACO deploy their existing Patient Care Tracker app to match it with patient data in the electronic health record in order to see and access program data. This TA Project aims to help the ACO:
- Enhance communication to medical providers in a way that is seamless and non-intrusive to existing workflows in the electronic health record.
Leverage the ACO’s previous investment in a Patient Care Tracker and build upon it to surface valuable data. (Added March 2022)
A TA Vendor is helping an ACO capture and coordinate the standardization of social determinants of health (SDOH) and health equity data elements in a centralized system for accurate reporting. The TA Vendor is:
Performing analysis with the intent to build/interface with MassHealth monthly csv data source ACO Partner EMRs, CP data, Care Needs Screening and HRSN data, Pioneer Valley Information Exchange data (local HIE) to consume race, ethnicity and language (REL) and demographic data elements.
- Coordinating with ACO resources to determine the best approach to consume these data elements in the patient information exchange.
The goal is to capture health equity related data such as REL, patient sexual orientation and gender identity and disability. During the course of this project, the TA Vendor is also conducting an analysis to determine the feasibility- both technical and process-based, of consuming SDOH assessment data from CPs to inform potential future work by the ACO. (Added March 2022)
This TA Project aims to better understand the barriers in accessing health care for the ACO’s patients with limited English proficiency or other communication challenges. The TA Vendor is exploring capabilities and best practices in serving non-English speakers through digital and written communications, the patient portal, and interpretation devices used during in-office visits. The TA Vendor is also translating existing patient-facing materials into languages other than English to help improve patients understanding of and compliance with treatment plans. (Added March 2022)
A TA Vendor is helping an ACO leverage their partners care management and community referral management system to operationalize the verification, planning, referral, and reporting aspects of the Flexible Services program. The ACO and TA Vendor are working together to automate program reporting and tracking features to create consistency across the provider and Social Services organizations that work in the Flexible Services program. The goal is to have a unified system and workflow for tracking and reporting that will reduce error and allow for efficiency and scale of programs. (Added March 2022)
A TA Vendor is facilitating a strategic planning retreat for an ACO’s Board of Directors to review strategy, operations, and begin planning for the new year and the projects to come. Goals of the strategic planning retreat include:
- Aligning on the strategic plan
- Confirming guiding principles and building components of a model of care to support primary care capitation
Aligning on a long-term vision for the enterprise to drive near-term planning. (Added March 2022)
An ACO TA Project seeks to demonstrate the connections between an ACO’s shared savings and shared losses results and the underlying member claims and budgets driving those results. The TA Vendor is enhancing a reporting framework to allow health center leaders to compare their results over time and identify areas of potential opportunity and focus. This reporting will give them a better understanding of their current utilization and cost contribution as well as performance on key quality indicators. (Added March 2022)
A TA Vendor is helping an ACO better understand its financial outlook for the upcoming year through use of actuarial consultants. The consultants are utilizing the 2022 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. (Added March 2022)
An ACO and TA Vendor are developing a training for ACO employees that includes: a critical grounding of the necessity for the group to come together to identify and implement anti-racist practices, a brief history of health care disparities, historical and contemporary examples that articulate the urgency of responding to oppressive and biased practices, guiding principles for engaging in difficult conversations, and strategies for the application of anti-racist practices. (Added December 2021)
An ACO aims to develop scalable, digital methods of engaging and treating patients. The ACO is working with a TA Vendor to build a series of digital tools responsive to member needs around navigating the health system. Additionally, these tools support primary care providers in managing complex medical/behavioral health patients. (Added December 2021)
An ACO is engaging in a TA Project with the goal of having a well-rounded understanding of members’ social risk profiles, ultimately allowing for data science to drive improved outcomes throughout the ACO. These improved outcomes would be observed through increased member engagement, enrollment in appropriate and beneficial care management programs, and increased data coverage and understanding of racial and ethnic disparities. The TA Vendor drives outcomes by completing at least two major analytical cycles. First, they are pursuing improving data coverage, with an equity lens. Then, the ACO and TA Vendor will select a second analysis to drive outcomes to the membership. (Added December 2021)
A TA Vendor is developing and delivering a series of workshops to strengthen an ACO’s knowledge and skills in the following areas: providing culturally responsive care to diverse populations; understanding addiction and supporting recovery; implementing a national program equipping staff with the skills necessary to respond to the signs of mental illness and substance use; and mental health topics for non-clinicians. Workshops include mini lectures, small and large group discussions, polls, and concrete tools for participants to use in their practice. (Added December 2021)
An ACO is engaging a TA Vendor to review, update and continuously improve its portfolio of strategies to deliver high quality effective transitional care and other services to reduce readmissions including behavioral health readmissions. This engagement involves analysis of current state of all post-acute transitional care practices; developing and updating a data-informed portfolio of strategies to reduce readmissions; and continuously improving performance through Plan-Do-Study-Act cycles, training, modeling and mentoring. (Added December 2021)
The purpose of this ACO TA Project is first, to clarify and document the care management strategies currently being implemented by one of the CPs with which the ACO is partnering, and second, to identify opportunities to expand key components of this partnership to the ACO’s broader CP network. The TA Project begins with a high-level assessment of the ACO’s CP program, followed by a deep dive into the ACO’s partnership to document the methods they are currently using for shared quality measures, health equity considerations, and reporting dashboards. The final deliverable is a roadmap to sustainably scale elements of the CP’s partnership across the full CP network. (Added December 2021)
An ACO is partnering with a TA Vendor to deepen the capabilities of health center primary care teams in successful population health management. The initiative includes two key design components. First, the TA Vendor will offer medical assistant training on the topic of “Interprofessional Team-Based Care” and “Quality Improvement and Making the Data Count.” The other key component comprises leadership accountability and support for chief medical officers and designated provider champions from ACO health centers to ensure the initiative is embedded within the health center’s overall strategy for team-based care improvement and achieves lasting change. The leadership group is discussing topics such as provider engagement, workflow re-design, medical assistant reward and retention, and overall care team satisfaction. (Added December 2021)
Through this TA Project, an ACO is working with a TA Vendor to improve integration of care processes and promote access to effective behavioral health care for pediatric members. The TA Vendor’s thorough analysis identifies concrete opportunities for improvement and helps the ACO design a model of care aligned with the needs of its members, as well as the goals of the MassHealth 1115 waiver and the Massachusetts Behavioral Health Roadmap. (Added December 2021)
A TA Project seeks to evaluate the Intensive Clinical Advisor (ICA) Program, which is designed to improve clinical outcomes and reduce high behavioral health inpatient and emergency department utilization through case review, team consultation, and referral/coordination with external resources. CHA’s internal analysis suggests that this program significantly reduces acute utilization and improves clinical outcomes by identifying the root cause of avoidable utilization and developing and implementing strategic interventions. This project will evaluate the program’s impact compared to an external control group of other MassHealth ACO patients. (Added December 2021)
An ACO is collaborating with a TA Vendor to demonstrate the connections between the ACO’s shared savings and shared losses results (at the ACO and at the individual health center level) and the underlying member claims and budgets driving those results. The TA Project includes developing a reporting framework to allow health center leaders to compare their results over time and in comparison to other health centers on an absolute and risk adjusted basis. Leaders at the ACO are able to analyze results by a variety of metrics to isolate performance drivers by rating category and region, as well as explore utilization by category of service, provider, and member conditions. (Added December 2021)
An ACO and TA Vendor are partnering to support housing initiatives, strengthen the ACO workforce’s ability to meet members’ health-related social needs, and improve population-level social determinants of health through person-centered, strengths-based, and legally-informed problem-solving strategies. The shared goal is increased health equity for people and populations served by the ACO by supporting both their medical/behavioral health needs and social needs around housing. The TA Vendor will educate and consult with ACO staff via several mechanisms: consultation, technical assistance, and training. The consults and training are conducted by a TA Vendor attorney who provides information and context that support the housing stabilization staff within the population health complex care management team to better partner with members regarding their legal risks, rights, and remedies that impact meeting health-related social needs. (Added December 2021)
An ACO and TA Vendor are partnering to strengthen the ACO’s ability to meet members’ health-related social needs and improve population-level social determinants of health through person-centered, strengths-based legal problem-solving strategies. The shared goal is increased health equity for people and populations served by the ACO. The TA Vendor is conducting trainings providing information and context that support the ACO and affiliated federally qualified health center staff to offer social care that is informed by members’ legal risks, rights, and remedies. (Added December 2021)
An ACO TA Project aims to conduct medical record review over-reads for 10% of the abstracted medical records. The project is identifying future opportunities to improve data entry and workflows at the ACO’s federally qualified health centers; collect all medical records; and highlight supporting evidence via charts for medical records selected by the auditor for the medical record review validation audit. (Added December 2021)
Through this ACO TA Project engagement, a TA Vendor is improving documentation accuracy to help the ACO better identify and fill gaps in patient care. The TA Vendor is reviewing 800 risk adjustable diagnoses codes and adding to a patient’s list of medical and social issues in an electronic health record, where appropriate. This TA will support the ACO’s ability to identify and meet patient needs by increasing primary care provider awareness of patient acuity and medical history, as well as allowing population health specialists to identify and outreach to patients who have unmet needs. (Added December 2021)
An ACO is engaging a TA Vendor to provide trauma-informed care training and implementation assistance, with an emphasis on supporting staff facing trauma themselves or working with patients impacted by trauma. This initiative supports a broader move towards trauma-informed services provided as a key component of value-based, capitated models of care for the ACO. (Added December 2021)
A TA Vendor is mentoring and overseeing the work of an ACO’s leadership team to identify a specific internal evaluation project and implement newly learned concepts and analytic methodologies for identifying data needs, collecting and analyzing data, and reporting out evaluation assessment(s) to the larger ACO leadership team. The TA Project builds on previous TA engagements where training was provided to the ACO’s clinical and administrative leadership team as well as the Data Analytics Division in: 1) developing evaluation and data analysis plans; 2) conducting analyses; and 3) interpreting data/evaluation findings to answer evaluation questions. The current TA Project bolsters the ACO’s ability to conduct internal evaluations in the future. (Added December 2021)
This ACO project extended work accomplished in a previous TA project with the same TA Vendor. In the second phase of this two-part project, the ACO expanded upon quality improvement and PCMH related work completed in the initial phase. Vendor efforts included assessing and operationalizing recognition standards throughout each practice site using a robust sustainability tool developed by the vendor. Additionally, the Vendor assisted in the implementation of social determinants of health workflows into patient care and initiated the medical home recognition process for a new practice site location. (Added July 2021)
A TA Vendor is building upon an existing list management solution to enhance an ACO’s data and reporting strategy. This effort focuses on streamlining the ACO’s internal processes and their centralized file inventory system. The TA Vendor expands upon the ACO’s interpretation of their 834 file and the downstream impact to the ACO and their partnering CPs. This effort also leverages an electronic health information exchange to deliver targeted clinical data elements to the care teams which drive workflow and provide insight into the patient story. (Added February 2021)
A TA Vendor is working with an ACO to better understand its financial outlook for the upcoming year through the use of actuarial consultants. The consultants will utilize the 2021 rate package from MassHealth, review all relevant materials, and construct a financial projection model. The modeling will help the ACO target performance improvement levels needed to achieve its financial goals. (Added February 2021)
A TA Vendor is providing consulting services to optimize transitions of care services for post inpatient admissions and emergency department visits. The TA Project includes a strategic evaluation and the recommendation of care management models to optimize sustainability, workflows, communication enhancements, and process changes. The TA Vendor will provide technical assistance to study current processes, identify barriers and opportunities, and support strategic conversations with leadership and other departments to implement changes for improved transitions of care call rates. (Added February 2021)
A TA Vendor has engaged in a joint project with an ACO and CP to use an evidence-based, person-centered, locally adaptable, and operationally feasible methodology for improving care and slowing the cycle of high utilization for multi-visit patients – the small percentage of patients who are utilizing a disproportionate percentage of acute care events. The objectives of this TA Project are to form an inter-departmental, cross setting action team, then implement the methodology to create a locally-relevant multi-visit patient care pathway and gain the skills needed to continuously improve the multi-visit patient care pathway over time. (Added February 2021)
A TA Vendor is providing information, resources, and training for primary care practice staff and clients around issues related to insurance coverage and access for autism resources and treatments. This is accomplished through a series of webinars for staff and clients, development of a resource guide for families, and informational brochures. (Added February 2021)
A TA Vendor is working with an ACO to strengthen its care team’s ability to meet members’ housing needs and improve health and social outcomes through strengths-based, role appropriate legal problem-solving strategies. Through the partnership, the TA Vendor is educating and consulting with the ACO’s housing advocates about housing-related legal rights, risks, and remedies during weekly interdisciplinary case review meetings. The TA Vendor provides legal information and context to enhance the team’s capacity to partner with patients interested in prioritizing health-related social needs like housing instability. (Added December 2020)
This TA project will support the electronic capture and exchange of data, including program eligibility, assignment to social service organization, referral tracking, invoicing and other information contained on the Verification, Planning, and Referral form related to each Flexible Service Program referral from initiation through to completion, to support the programs. This project will make available to social service organizations secure messaging and a portal through which they can receive referrals and complete care plans. (Added December 2020)
An ACO TA Project is focusing on interoperability and automating weekly updates to its registry. The solution aims to eliminate the need for manually prioritizing patients and addresses patients with quality care gaps by automatically creating new tasks and deadlines within the management system for community health workers. This TA Project works to support the goals in the DSRIP participation plan by automating current manual work done across the ACO to identify patients for outreach. Elimination of this manual work is estimated to be .5 full time equivalent staff per health center; this work can be redirected to patient care. (Added December 2020)
An ACO is engaging a TA Vendor to create and execute a study design to measure the cost effectiveness of its care management programs and initiatives focusing on high-need, high-cost individuals. The project is looking at these programs’ effects on specific quality metrics and total cost of care. (Added December 2020)
An ACO TA Project is designed to ensure accurate reporting of the delivery of flexible services to MassHealth and, to identify opportunities to improve the delivery of person-centered medically-tailored meals flexible services. The TA Vendor is supporting the ACO by compiling and reporting flexible services data to MassHealth, monitoring enrollment and service delivery data, identifying opportunities for improvement. (Added December 2020)
A TA Vendor is collaborating with the teams at an ACO to scope, design and implement flexible services programs across the network. The TA Vendor is supporting the ACO’s goal to expand its current flexible service program by providing technical expertise and project management for the team. The TA project is divided into two phases, including immediate work to operationalize flexible services programs as a part of the ACO’s COVID-19 response, and then a longer-term phase to develop a new flexible services program. (Added December 2020)
A TA Vendor is collaborating with an ACO to implement a system of project management and support to help the ACO to produce various reporting deliverables to MassHealth effectively (i.e. timely and accurately) and efficiently (i.e. with minimal negative impact on resources). This project focuses on identifying resources needed, establishing roles and responsibilities, managing timelines, filling gaps, gathering data and information, ensuring compliance with MassHealth requirements, ensuring strategic discussions are well-informed and involve the appropriate staff, and ensuring timely and accurate completion of deliverables. The project aims to improve capacity, performance and sustainability of the ACO by optimizing decision-making regarding investments and strategy, identifying required staffing, establishing team roles and responsibilities, and implementing repeatable processes. (Added December 2020)
An ACO is working with a TA Vendor to design and operationalize a health-related social needs screening and referral process to utilize within its primary care practices. Enabling primary care practices to perform this critical function will help ensure that more members are screened and receive timely referrals to address critical social needs. In turn, this should contribute to lowering the total cost of care and improving health outcomes. (Added December 2020)
A TA Vendor is providing support and consulting to help an ACO deploy their Health Coordinators in a new initiative supporting telehealth. The ACO is expanding the role of Health Coordinators to include home visits with patients to increase patient engagement with preventive and specialty care and meaningfully engage with patients to reinforce care plans developed between patients and providers. This will include having Health Coordinators set up tablet computers in patients’ homes, facilitate virtual visits with ACO providers via the tablets, connect patients to the ACO’s online patient portal, and facilitate the closing of gaps in care to support patients’ health and preventative health activities in these challenging times. The TA Vendor is developing and documenting processes and workflows for Health Coordinators to coordinate care for patients who need assistance connecting with their providers in a virtual format, and also developing a comprehensive, standardized training program for the Health Coordinator staff. (Added December 2020)
An ACO TA project is training Community Health Workers (CHWs) to engage with the families of Children and Youth with Special Health Care Needs (CYSHCN) who are enrolled in the ACO. The project will help the CHWs and the ACO to have meaningful interactions with families of CYSHCNs as they navigate complex health and education systems. Much of the training involves developing shared planning and prioritizing with families, and also specifically emphasizes the ways that CHWs can help families remove barriers to accessing services in the health and education sectors. (Added June 2020)
An ACO is engaging a TA Vendor to help design and operationalize a Flexible Services Program. The goals of the program are to reduce the total cost of care by 2% over the next five years for the entire population, and reduce total cost of care by 5% over the next five years for patients enrolled in either of the two Flex Services programs; and improve health outcomes among patients with diabetes, hypertension, and/or a behavioral health diagnosis. (Added June 2020)
An ACO is receiving support from a TA Vendor to develop patient education materials to address chronic conditions, such as diabetes, heart failure, and chronic obstructive pulmonary disease. The TA project is part of a broad effort to drive improvements in patient outcomes at the ACO. The project closely links patient education to digital health efforts that seek to create a broader framework for patient engagement. (Added June 2020)
An ACO is working with a TA Vendor to implement Medically Tailored Meals (MTM) as a Flexible Service. The TA project is working with the ACO sites to ensure they are able to provide MTM efficiently; develop effective policies, procedures and workflows; and manage financial, reporting, and compliance functions. (Added June 2020)
A TA Vendor is working with an ACO to provide project management support for the implementation of a Flexible Services software platform supporting care teams to communicate directly with social service organizations, and provide an ongoing platform to deliver holistic, longitudinal care to high-risk members. This project will enable care teams at the ACO to ensure members receive timely and appropriate social services 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. The ACO is using the system to authorize, track, and reconcile services delivered by the social service organizations. (Added June 2020)
A TA Vendor is assisting an ACO with the development of a metric that will be used in conjunction with the risk scores of members attributed to each PCP group within the ACO. The ACO, as a consortium of many provider groups, has large variances in the underlying health status and social determinants of health of their members, and consequently experience large variances in costs. The TA Vendor is assisting the ACO to identify and quantify these variances such that the overall ACO budget can be allocated across provider groups in a way allows for adequate funding and preservation of the core principles of the ACO partnership. (Added June 2020)
A TA Vendor is collaborating with an ACO to develop a process to manage and coordinate member assignments to CPs through a centralized system. The project provides an electronic means to manage and track the care plan/comprehensive assessment workflow for organizations connected to a regional health information exchange. This system aims to provide the ACO convenient insight into the care plan and comprehensive journey of a member through a web-based dashboard, allowing participating organizations access to a visible representation of a member’s current stage in the process. (Added June 2020)
A TA Vendor is developing and delivering a customized training for an ACO focused on motivational interviewing and its applications to the ACO’s health-related social needs screening. The training is intended for both nonclinical and clinical staff within the ACO’s health centers. The ACO is aiming to infuse motivational interviewing techniques within their health centers with the goal of screening for a wider range of patient social needs to aid in accurate triage and referral to services. (Added February 2020)
A TA vendor is collaborating closely with an ACO to implement key strategic process enhancements to improve efficiency and member outcomes. Improvements align with evidence-based practices for discharge planning and care transitions to reduce readmissions. Further, the TA Vendor is collaborating with the care management staff and leadership to improve the referral and member engagement processes. Taken together, these two work streams aim to contribute to the ACO’s goal of a 2% reduction in readmissions this year. (Added February 2020)
With assistance from a TA Vendor, an ACO is launching a new housing initiative centered on persons experiencing homelessness or at risk of homelessness and avoidable care utilization. The ACO has established strategic partnerships with local housing authorities to optimize patient access to scarce housing resources. In the process of partnering with members experiencing housing instability, a number of legal risks or barriers may arise, relating to criminal system involvement, eviction history, or reasonable accommodations requests to landlords. The TA vendor is training the ACO and its care management staff to recognize these legal risks and remedies as well as scope-of-practice-aligned problem-solving strategies they can deploy with patients navigating housing instability. (Added February 2020)
An ACO is implementing a cross-setting care pathway to improve care for multi-visit patients, to help it achieve important clinical, operational and organizational capability goals. These goals include: understanding the drivers of utilization of multi-visit patients, and developing the interdisciplinary cross-setting team based cultures, norms, processes and work flows to support improved service delivery over time. The ACO and TA Vendor are utilizing a rapid-cycle continuous improvement methodology to inform and implement continuous improvement efforts. (Added February 2020)
A TA Vendor is collaborating with an ACO to uncover new opportunities to engage with members and deploy interventions addressing social determinants of health. The TA project is surfacing the social determinant acuity of the entire population, identifying patients who are candidates for a complex care management program, and helping the ACO understand the various challenges of contacting and engaging members. 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. (Added February 2020)
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. A TA Vendor is assisting the ACO with redesigning procedures, training staff in competencies, and training supervisors in practices to support the professional development of PCFs. Training topics for PCFs 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). This additional training aims to enable PCFs to better support pediatricians’ efforts to remediate the impact of social determinants of health and adverse childhood experiences. (Added February 2020)
An ACO project aims to strengthen its efforts to engage members in managing their health. The project is also focusing on increasing the effectiveness of the ACO’s care management team by allowing them to more efficiently and successfully address social need challenges experienced by members. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)
CP Projects
A TA Vendor is providing technical assistance to a CP on three projects to help them improve member outcomes that include:
- Reduce Emergency Department (ED) and acute care readmissions for individuals with substance use disorder (SUD)
- Improve health and wellness outcomes for engaged members
- Improve the engagement rate for assigned members
TA consists of internal and external strategic planning, supporting integration efforts with the CP’s primary ACO and helping to develop and implement enhanced workflows. Specifically, the TA Vendor will support the development and implementation of targeted interventions for the BH CP quality measures. This TA Project supports the BH CP’s sustainability by demonstrating the positive impact of several quality measures for the SUD population. (Added March 2022)
A TA Project is helping a CP implement the Multi-visit Patients (MVP) Method by forming an inter-disciplinary, cross setting action team, learning new skills, developing new tools and processes, and implementing the elements of the MVP Method to create a locally relevant MVP care pathway, and gaining the skills needed to continuously improve the MVP care pathway over time. (Added March 2022)
A TA Vendor is helping a CP improve its population health management, manage its assigned members more effectively, and demonstrate value to the ACOs that refer to the CP. They are collaborating on:
- Improving the skills of behavioral health CP managers in accessing and reporting from the BH CP Dashboard developed on key measures of emergency department (ED) Utilization, inpatient utilization, pharmacy utilization, and annual wellness visits.
- Developing value propositions to ACOs on outcomes of assigned members based on utilization of ED and Inpatient services.
Assessing and improving workflows to increase the rate of members completing a care plan within 122 days, including training staff and use of data to track member journey from assignment to care plan completion. (Added March 2022)
In this CP TA Project, the TA Vendor is performing discovery and collecting detailed requirements to integrate an electronic health record system currently being used by one of the CP’s agencies. This project will achieve the following goals:
- Provide the CP with detailed specifications to consume the partner’s electronic health record data, based on an agreed-upon list of data elements.
- Based on requirements collected, develop a draft implementation plan with estimates on effort.
The CP will be able to use the documentation to design, develop, test, and deploy a functional data interface from the electronic health record into their existing enterprise data warehouse. Once implemented, this interface can potentially be used to consume data from other electronic health record systems utilized by any of the CP’s agencies. This TA project aims to help the CP perform more advanced analytics, such as predicting events, utilization, and health status based on modeling the patterns that exist in the captured data. (Added March 2022)
A TA Vendor is supporting CP partners evolution as a MassHealth BH CP program and a LTSS CP program and with the sustainability of the two programs. This project aims to support the CP partner’s sustainability by creating the value proposition materials needed to strengthen current ACO/MCO relationships and contracts. (Added March 2022)
A TA Vendor is helping CP partners improve data collection for the required patient information exchange and reduce the manual exchange of care plans with primary care providers. The TA Vendor will help the CP partners integrate their information with the patient information exchange and transmit the care plans electronically. (Added March 2022)
A TA Vendor is helping a CP by providing training to clinical leaders on remote patient engagement to respond to the rapid shift in using remote care. The training includes concrete tools to adapt to the changing environment, including staff support tools and methods to understand the psychosocial impact on staff, and how to build staff resilience. Key training topics include quality care support in remote engagement models, retaining staff accustomed to community-based engagement in a time when the work and engagement models change, and supervision strategies and best practices for sustainability when traditional community engagement models resume. (Added March 2022)
A TA Vendor is conducting a training for CPs to help staff identify their current state of data collection and distinguish between internal and external data usage. Participants are learning why data is important in current and future decisions, how to recognize a variety of decision-making strategies using data, and how to evaluate their current data—the collection of it, the analytics, and the return of results to increase effectiveness and efficiency in their operations. (Added March 2022)
A TA Vendor is helping a CP partnership strengthen their electronic health record documentation and bolster care coordination so it is in line with high-quality care and best practices for documentation. In this TA Project, the TA Vendor is developing templates and associated prompts that help staff adopt a standard documentation process. This process aims to ensure the type of content documented is consistent across all members’ electronic medical records. Templates will support documentation of care coordination activities such as outreach; comprehensive assessment; social needs assessment; initial, 90-day, and annual care plan completion; disenrollment; monthly contact with member; contact with collaterals; and transition of care. (Added March 2022)
A TA Vendor is helping a CP partnership leverage the data analytics and reporting platform that the TA Vendor built to automate manual processes, identify gaps in qualifying activities provided to members, and identify other relevant quality care gaps. The platform aims to showcase to the ACOs and MassHealth the impact of the CP partners in the community and with its members, so they can identify areas for improvement. This TA Project will develop more automated processes to give the CP teams more bandwidth so they can focus on member care. (Added March 2022)
A TA Vendor is delivering a training to CP partners to help them provide non-clinical support for people living with mental health challenges. Participants are learning to recognize signs and symptoms of common mental health challenges, and how to provide coaching for mental wellness that is culturally responsive and trauma-informed. Participants are also examining personal and societal biases about mental illness and learning about the negative impact of stigma so they can challenge and reduce stigma. (Added March 2022)
A TA Vendor is delivering a virtual, half-day training on outreach, engagement, and retention with Individuals who are homeless. The training covers key concepts for successfully working with this population, including harm reduction, trauma-informed care, and using a strengths-based approach. The goal of the training is to prepare care coordinators, outreach workers, nurses, and related staff and supervisors/managers to effectively connect with and support individuals experiencing homelessness so they can successfully engage in health and behavioral health services. (Added March 2022)
In this TA Project, a TA Vendor is helping a CP’s care team members learn behaviors required to build authentic healing relationships, build patient self-efficacy, create sustained behavioral change, and track progress with goals. The TA Vendor is training care team members how to break down relationship building and empowerment into actionable behaviors. (Added March 2022)
A TA Vendor is providing training to enhance a CP’s nurse care management team capacity, work experience, and performance. This TA engagement is focusing on clinical leadership and nurse care manager engagement, professional development, and process/quality improvement activities. The goal of this TA is to positively impact employee work experience and client outcomes through improvements to clinical, operational, population health and financial performance. (Added March 2022)
A CP is working with a TA Vendor to increase culturally responsive care and linguistic capacity through a beginner language and culture course that serves as an introduction to Spanish for frontline workers who interact with patients in recovery from a substance use disorder. The 70-session course is designed to provide students with the necessary skills to effectively communicate in basic everyday situations in the healthcare setting with Spanish-speaking patients namely from the Caribbean, Central America, and South America. (Added December 2021)
A TA Vendor is delivering a 60-hour medical interpreter training course in which fluently bilingual individuals develop the skills necessary to facilitate effective and reliable interpretation in clinical and human service settings. This course provides students with principles, methods, and competencies (both knowledge and skills-based) essential in the delivery of effective, reliable, and comprehensive interpreting. This course develops a theoretical and practical understanding of the multiple roles of the interpreter as well as the related ethical, cultural, and linguistic challenges in this evolving field. (Added December 2021)
A TA Vendor provides TA to a CP to help expand and enhance organizational capacity and quality/performance improvement initiatives. This TA engagement focuses on executive-level strategic advising, clinical leadership engagement and development, and process/quality improvement activities with the goal of positively impacting member outcomes through improvements to clinical, operational, and financial performance. (Added December 2021)
A workforce development TA Project supports LTSS care coordination tailored to the unique needs of children, youth, and their families. The project is focusing on strengthening the scope of practice and key core competencies staff need to ensure access and linkage to a variety of child- and youth-specific medical, social, and behavioral health resources and services. This aims to afford staff the support they need to operate within the limits of their scope and prioritize multiple complex needs across a large caseload while managing expectations in line with what is feasible within the child-, youth-, and family-serving system of care and the local community. (Added December 2021)
Working with staff at a CP, a TA Vendor is providing a multipronged project to increase culturally responsive care, increase staff knowledge of components of care coordination through a training miniseries, provide peer recovery coach training, and conduct a community health worker core competency training. These trainings are delivered via six-to-eight-hour sessions. (Added December 2021)
Working with staff at a CP, a TA Vendor is providing trainings to increase staff knowledge of medical terminology, anatomy and physiology and population-specific, culturally responsive workshops on beliefs and barriers. The overall goal is to strengthen engagement with members and their families to provide quality care to the diverse populations the CP serves. Objectives include increasing the understanding and knowledge of medical terminology, anatomy, and physiology for frontline staff; and increasing the ability of staff to provide culture and population specific culturally responsive care. (Added December 2021)
A TA Vendor works with a CP to advance the effectiveness of its redesigned community advisory board. This initiative builds the CP’s internal capacity to achieve long-term success in garnering input from the community to assist in the organization’s ability to take actionable steps toward achieving improved care, improved health, and reduced cost per capita. The project will establish a leadership structure and working groups within the community advisory board and focus on building community engagement and capacity building skills to improve the quality of care and services, bringing to care those who are often considered hard-to-reach. (Added December 2021)
A CP is working with a TA Vendor to hold two half-day retreats for CP teams aimed at improving communication between teams; building relationships among team members; and getting to know teammates who are mostly remote. The retreats are bringing together clinicians, case managers, and behavioral health professionals who work in many different locations delivering quality health care to some of the community’s most vulnerable and resilient members. (Added December 2021)
A TA Vendor is working with a CP to implement a methodology to slow the cycle of utilization for multi-visit patients by forming an inter-disciplinary, cross setting action team, teaching new skills to the CP, developing new tools and processes, implementing the elements of the methodology to create a locally-relevant multi-visit patient care pathway, and conferring the skills needed to continuously improve the pathway over time. (Added December 2021)
Working collaboratively with a TA Vendor, several CPs are participating in a joint TA Project to gain more insight into total cost of care and operational trends. By analyzing claims and electronic health record data, each CP will be able to develop a deeper understanding of the impact the CP program is having on health-related expenditures for the member population. (Added December 2021)
A CP TA Project aims to deliver improvements to available software and workflow processes to increase the automated integration of separate data systems; increase the efficiency of data exchange processes with MassHealth and ACOs; provide care coordinators with easier access to patient information; and provide more timely program performance information. (Added December 2021)
A CP is engaging in TA to build a data analytics and reporting platform to provide automated reporting to help the CP monitor its performance. The platform analyzes the data from MassHealth claims and facilitates coordinated care for its members. In addition to analyzing claims and utilization, the CP can use the platform to perform care gaps analysis based on MassHealth quality measures to improve the health of its members. Further, the platform automates the reporting for ACOs/MCOs, which was previously done manually. (Added December 2021)
A CP engages a TA Vendor to build advanced data analytics, using their existing data warehouse, to include insights based on health equity. The CP is operationalizing stratification measures and analytics to understand the patterns of behavior across different cohorts of populations and look for opportunities to improve health of these members. The CP aims to acquire deep insights about high-risk members and their utilization details at a population and individual level and build processes for timing interventions to reduce the total cost of care and improve health. (Added December 2021)
A CP is engaging a TA Vendor to provide TA in creating custom health quality measures to support payment requirements for certain qualifying activities. In addition to creating custom health quality measures, the TA Vendor is creating population health reports that will allow their entities to provide information to our care coordinator staff to reduce acute care utilization and increase primary care engagement and engagement in the CP program. (Added December 2021)
A CP is collaborating with a TA Vendor to develop an analytic framework to help understand enrollees from a population health perspective by identifying high need/high-cost populations, and achievable opportunities that will lead to effective interventions in support of enrollees in the CP program. The project goal is to update and enhance the CP’s centralized data repository for MassHealth claims and enrollment data to assist the CP in providing effective integrated care management. (Added December 2021)
A CP is engaging a TA Vendor to assist in evaluating current overall performance and results and identify strengths and actionable performance gaps and improvement opportunities. The TA Vendor reviews and evaluates the CP’s capabilities and performance of core LTSS CP functions and responsibilities, assisting the CP to identify strategies and tactics that strengthen and further demonstrate their unique value to their ACO/MCO partners. The TA Vendor is reviewing organizational data to examine key LTSS CP performance measures and results, conducting interviews with selected stakeholders to evaluate current state, and performing a gap analysis. The TA Vendor assists the CP in evaluating use and reporting of available data to their ACO/MCO partners and identifying potential opportunities to present data more effectively, to further demonstrate value to their ACO/MCO partners. The TA Vendor is also providing a summary report of findings and recommendations and developing a performance improvement action plan. (Added December 2021)
A TA Vendor is partnering with a CP to develop and customize a solution that provides reporting capabilities to support review, integration, and analysis of data populated by identified data sources such as MassHealth and electronic health record referral data, assignment files, and claims data. The TA Vendor is developing and customizing dashboards and actionable reports that allow the CP to efficiently review data necessary to develop real-time, meaningful, and streamlined service plans for members. (Added December 2021)
The goal of this TA Project is to expand and enhance a CP’s current reporting capabilities using the monthly MassHealth claims files to understand the trends of its members’ service usage more thoroughly. By identifying members who are underutilizing services (for example, preventative care services) or overutilizing services (such as emergency departments), the CP can apply risk stratification management to members in need of extra support. (Added December 2021)
A CP TA Project is developing and refining predictive modeling tools to support enrollee risk stratification and care coordination efforts. Using MassHealth claims data and CP LTSS assessment data, the TA Vendor is reviewing the CP’s datasets and developing methodologies, recommendations, and next steps for statistical analyses of member demographics, functional characteristics, and social determinants of health in relation to emergency department use. (Added December 2021)
In collaboration with a CP, a TA Vendor is conducting, developing, and delivering customized training to improve the competencies and skills of the CP’s care coordinators. The TA Vendor will deliver an Online Module, conduct a Learning Needs Resource Assessment, and deliver nine trainings via webinar to improve care coordinator competencies and skills that best impact clinical quality, patient and provider experience, and cost. (Added February 2021)
A TA Vendor is working with a CP to support data and reporting capacities in order to enable CP staff to further aggregate and compare patient-based data segments; analyze the impact of care management and clinical interventions; and access MassHealth claims data for analysis and reporting. (Added February 2021)
A TA Vendor is enhancing a CP’s understanding of the population health of members served through the CP program. The TA Vendor analyzes members’ claims data and builds reports to represent members’ cost and utilization, trends in use of services, and how individual members are using services. In addition, the TA Vendor creates a Quality metric report looking at the CP’s performance in relation to the quality measures established by MassHealth. (Added February 2021)
A TA Vendor is supporting CP leadership and care teams by providing training on five key content areas and skills for member engagement with additional training for supervisors to sustain gains: Motivational Interviewing and Stages of Change; Using Assessments to Develop Person-Centered, Comprehensive Care Plans; Common Co-occurring Medical and Behavioral Health Diagnoses; Care Coordination Strategies for Members with Opioid Dependence; and Using Telehealth for Care Coordination. (Added February 2021)
A TA Vendor alongside a CP’s leadership and frontline staff are spearheading the development of a more diverse, engaged, and effective community advisory board. The development of sustainable structures includes the refining of the community advisory board handbook; a documented and well-articulated recruitment and retention plan; engagement and training of a care coordination team; and mentoring and coaching of current staff and community leaders to effectively design, plan and facilitate community advisory board meetings and implement retention strategies. (Added February 2021)
A TA Vendor is supporting a CP to establish systems necessary to manage internal and external data from health technology companies for its Long-Term Services and Supports CP program; leverage the historical and future data captured through the CP’s electronic health record system, external sources such as MassHealth claims, and the risk stratification systems of partner ACOs, to evaluate member outcomes; and build data analytics competencies within the organization. (Added February 2021)
A CP is engaging a TA Vendor to develop and provide training for care coordinators and nurse care management staff on strategies and activities to increase and sustain member engagement. The TA Project includes remote focus groups with staff to obtain input regarding the specific challenges front-line care coordinators face in sustaining ongoing engagement with enrollees, including any geography-specific challenges. The information from focus group participants will inform the development and delivery of training for front-line staff on effective enrollee outreach and engagement. (Added December 2020)
A TA Vendor develops an analytic framework that helps a CP understand the path to financial sustainability under MassHealth. The TA Vendor uses models and projections to simulate paths forward to achieve financial stability for the continuation for the CP’s Behavioral Health CP Program after the end of DSRIP funding. As a part of this project, the data warehouse that was completed in the first TA Project with the TA Vendor is refreshed and delivered to the CP. This data then informs the financial models. The TA Vendor clinicians connect with CP staff to hold interviews discussing program operations, model of are, desired program outcomes and expenses, and staffing models. All of this is collected and incorporated into the final analysis. Final outcomes of the project produce an excel format model that can be manipulated to test different spending and saving plans for financial growth and stability. (Added December 2020)
A CP TA Project is leveraging existing quantitative and qualitative data streams including electronic health record data, local homeless management information system data, social needs screening data, claims from MassHealth and ACOs including medical, behavioral, and social to better analyze the CP’s population characteristics, and better describe the progress and the challenges to achieving goals at the ACO level. The project is also exploring the feasibility of integrating additional data to strengthen the CP’s value, efficiency and effectiveness including criminal justice data as well as integrating data from affiliated partners’ electronic health records. (Added December 2020)
A CP would like to improve its understanding of its Long-Term Services and Supports CP population and program through a comprehensive qualitative and quantitative analysis of this program. Through this project, the TA Vendor and the CP will identify opportunities to improve performance, drive better outcomes for its members, and strengthen its relationships with ACOs. (Added December 2020)
A TA Vendor is conducting an analysis and 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. (Added December 2020)
Phase three of a CP TA Project seeks to develop 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. (Added December 2020)
This CP TA project is phase two of a project with a TA Vendor. The first phase of this project included the strategic planning and model design for a performance improvement pilot testing developed workflows with select ACOs to demonstrate improved health outcomes for shared members on specific CP and ACO quality measures. Phase two of the project is the implementation of a three-month pilot with three ACOs followed by an impact analysis. The TA project’s focus on working jointly on shared quality measures will support success for both the ACO/MCOs partners and the CP. (Added December 2020)
A CP TA Project is focusing on making its communications more robust through effective, comprehensive, multicultural marketing and engagement strategies. A TA Vendor is helping the CP launch a full outreach assistance campaign to allow the CP to boost its outreach capacity, including support by the TA Vendor’s organizers that will provide capacity at non-traditional hours. The TA Vendor is also providing a targeted effort to increase awareness of the CP’s brand among ACOs through creative elements such as branded logos, photos and new content like testimonials from staff and clients. (Added December 2020)
The focus of a CP TA Project is to improve engagement with and delivery of care coordination and related support services to a CP’s MassHealth members. This is done through a series of “whole person approach” trainings for care coordinators that increase staff knowledge and skills when working with members who have complex medical and behavioral issues. Training focuses on the following topics: overview of substance use disorders, overview of dual diagnoses/co-occurring disorders, understanding homelessness and housing options/policies for people with behavioral health disorders, and several special topics in mental health, including social anxiety and agoraphobia, hoarding and clutter disorder, managing terminal illnesses/end of life issues and, establishing and maintaining professional boundaries. (Added December 2020)
As part of an initial engagement with a CP, a TA Vendor is developing a comprehensive data model to handle and manage the ingestion and analytical output of MassHealth claims data. This initial Proof-of-Concept utility requires significant technical aptitude to maintain. In addition, multiple disparate data sources have become available to the CP that enables near real-time clinical and care coordination utility. This TA Project aims to further enhance data utilization into clinical workflow and clinical decision making. (Added December 2020)
This project focuses on helping a CP’s care coordination staff increase their performance on a MassHealth metric by more consistently completing a follow-up visit within three business days following a member’s discharge from an acute or post-acute stay. This will involve an assessment of the current state of follow-up after discharge activities, an analysis of best practices in this area, the development of a revised workflow and processes to bridge the gap between current and revised practices, and a “train the trainer” to establish the new workflow and associated procedures. (Added December 2020)
This project focuses on helping a CP’s care coordination staff decrease the time it takes to engage newly assigned MassHealth members, as staff strive to meet a MassHealth quality measure. The quality measure requires that CPs document enrollee engagement within 122 days of the date of enrollee assignment and that care coordinators must complete a comprehensive assessment (for Behavioral Health CPs) and develop a person-centered care plan, which is then approved by the member and their primary care physician or designee and submitted to the Medicaid Management Information System. This project involves an assessment of the current state of outreach and engagement activities, an analysis of best practices in this area, the development of a revised workflow and processes to bridge the gap between current and revised practices, and a “train the trainer” to establish the new workflow and processes. (Added December 2020)
A CP is working with a TA Vendor to fully engage and integrate the voices and values of behavioral healthcare consumers in the CP’s services, programs, and decisions. Using best practices, the project is identifying a community advisory board composed of community and behavioral health care consumers. The project includes developing new community engagement plans and supporting implementation of outreach activities. The TA Vendor is also developing a training curricula to support consumer engagement and recovery-oriented culture to educate staff and leadership on recovery-oriented practices and services and consumer engagement. (Added December 2020)
A TA Vendor is analyzing finances, claims, and revenue cycles to determine a CP’s overall billing performance and identify any areas for improvement. The TA project aims to establish the nature and scope of any revenue cycle breakdowns as evidenced by workflow and the available data. The TA Vendor is reviewing business processes and financial information, including claims submitted, claims paid, claims denied, and other claims data to detect where the issues exist and will develop recommendations to address these issues. (Added June 2020)
A TA Vendor is leading the delivery of special topic trainings for a CP’s care coordinators on topics such as diabetes, cancer, mental illness, and addiction. The training series is comprised of topics prioritized by staff where further learning needs were identified. The trainings include modules on culturally responsive care with a focus on cross-cultural communication to specific populations served by the CP and practice-based motivational interviewing training building upon the community health worker core competency course. (Added June 2020)
This project, involving multiple CPs, will enable the CPs to build out a suite of comprehensive quality reports and dashboards important to providing quality care coordination services. Access to this data provides CPs with the opportunity to analyze data trends and develop agency workflows to address performance improvement on quality measures. (Added June 2020)
A TA Vendor is working with a CP to gather input and feedback from key stakeholders at the CP as well as at its respective ACO partners on the current state of the CP program and ACO/CP integration initiatives as well as the future state of the CP program. This information will allow the CP to identify priorities and strategic opportunities for promoting the sustainability of the CP program while building effective and sustainable relationships with its ACO partners. (Added June 2020)
A TA Vendor is conducting an environmental scan, developing an equity framework and an equity evaluation and monitoring plan (including analytic approaches and instrument development or enhancement), and preparing a final report that includes recommendations for infrastructure and communication with staff around clinical equity. The TA project aims to support the CP in developing a process for understanding and tracking whether disparities currently exist in their performance metrics so that, if disparities are uncovered, the CP can engage members in discussions on how to eliminate those disparities. This work will support continuous quality improvement by helping the CP understand and track whether all populations in their practice and CP program are benefiting equally from their work. (Added June 2020)
A TA Vendor is creating a sustainable training infrastructure for a CP to help structure their educational programs into an organized, vibrant learning platform. This effort will capitalize on the skills and experience of the CP’s most seasoned staff while creating engagement and growth opportunities for all employees. The training aims to engage learners on a regular basis to ensure competency and compliance. (Added June 2020)
A TA Vendor is developing a comprehensive training program focused on population health management principles that address the unique needs of CP staff at different levels of the organization. The project will engage CP leadership to explore how to effectively and efficiently collect, integrate, analyze, and report data from MassHealth partners and the electronic health record platform moving forward. (Added June 2020)
A CP is working with a TA Vendor on a multi-phase project to develop and implement a data integration and online reporting solution. The TA Vendor is customizing a solution for the CP with query capabilities to support review, integration, analysis, and trending of data populated by identified data sources such as 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 internal case management system. This integration will allow the CP to efficiently use care team resources by creating 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. (Added June 2020)
A TA Vendor is providing an analysis of a CP’s program workflow, processes, and staffing for the initial engagement of members. The TA Vendor is conducting a comparison of current team processes against best practices and identifying the financial/organizational impact of recommended changes. They are also making recommendations for revised workflows, processes, and staffing models to improve rates of outreach activities to optimize billable per member per month payments, improve rates of engagement, and improve performance on quality measures. (Added February 2020)
A TA Vendor is working collaboratively with a group of 16 CPs to improve care coordination for members by enabling access to member-level MassHealth claims data directly from the TA Vendor’s CP Care Management Platform. By integrating claims-level data into a member’s chart, end users are able to get an at-a-glance understanding of a member’s medical history and total cost of care. The TA Vendor will supply technical assistance, including training, support, and analysis, to support CPs in effective use of MassHealth claims data. (Added February 2020)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added December 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added September 2019)
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. (Added April 2019)
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. (Added April 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. (Added April 2019)
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. (Added April 2019)
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. (Added April 2019)