Slide 1: Commonwealth Care Alliance
One Care Implementation Council Presentation
October 13, 2020

Improving care for people with disabilities and chronic health needs
Slide 2: Primary Care is the history of CCA
•	CCA began as Urban Medical Group more than 40 years ago, founded by Drs. Bob Master and Marie Feltin as an option for people not served well by the system
•	Even as CCA began as an integrated payor/provider system, primary care continued to be primary with Boston Community Medical Group and the development of Commonwealth Community Care
•	Close partnerships with FQHCs, Safety Net Hospitals, and others in the Commonwealth
•	Continued growth and innovation to serve more dually eligible people in the Commonwealth, while not forgetting our roots

Slide 3: CCA Primary Care: By the Numbers
•	1,500 members at CCA primary care clinics, with projections to grow to over 2,000 by 2021 EOY
•	Four clinic locations in Boston, Lawrence, Framingham, and Springfield
•	30 CCA primary care clinicians, majority NPs
•	Average between 5,000-6,000 encounters per month, maintained during Covid-19.  1000 clinic visits; 4500 virtual visits; More than 2000 home visits. 
•	99% of SCO members and 97% of One Care members aligned with CCA primary care were contacted in the last 90 days
•	2019 revenue was ~$67M, with 2020 revenue projected to be over $90M

On the other half of the page there is a silhouette of a house, labeled Primary Care Site. There are two lines to show that the following images and words are services provided inside the Primary Care Site house: Engagement Center (meals, neighborhood, education), Chronic Diseases, Behavioral Health, CCA Resources, Hospital building, a picture of a bed, and Support Groups.
Slide 4: CCA Member Snapshot
•	Average HCC score 3.4 (does not include FFS)
•	Average PMPM spend for LTSS (over past 15 months)
•	One Care: $621 
•	SCO: $1,228 
•	Average over five telephone encounters per SCO/OC member per month from the clinical teams
•	Average number of provider visits per patient per month: 
•	1.3 since COVID
•	1.5 pre-COVID

The following information is displayed in a pie chart:
CCA Membership by Condition (data from 2017) 

Neurodegenerative conditions	21%
Severe disabilities	18%
SPMI	25%
SUD comorbid 	6%
7+ chronic conditions	6%
4-6 chronic conditions	7%
All other	17%

Slide 5: eMOC (evolved Model of Care) Objectives
Why are we doing this? 
•	To prepare for the future and serve more individuals
•	To obtain the best outcomes for our members
•	To invest in our teams
Slide 6: Patient Centered Care: Challenges
Legacy Model

Goal of 2017 model is to match a member’s need(s) to the appropriately skilled care partner, but there are barriers and inefficiencies:
•	Members are complex with varying degrees of medical, behavioral, and social needs that flux over time
•	Care management and care coordination activities have high administrative burden

In our current state, we have begun to address some of these challenges:
•	Created centralized authorization unit – continues to evolve into a high performing and efficiently operating team
•	Implemented Guiding Care (Care Management Platform) takes us to high level standard practice
•	Adopted medical policies and standardized UM criteria with InterQual (evidence-based clinical decision support criteria)
Slide 7: Member view of evolved care model: Access to interdisciplinary team
Example CCA member: 78-year-old Mary has depression, loneliness, congestive heart failure, dementia, no transportation, nearby kin or support

There is a silhouette of a person in the middle (Mary) with lines pointing to the CCA team supporting her: NP/PA* (addresses Mary’s CHF, dementia), BH (addresses Mary’s depression and loneliness), RN/LPN, HOW (provides Mary SDOH support), RN Care Partner*.

*All CCA Members will have access to an RN care partner and advanced practice clinician (NP or PA)
Slide 8: Interprofessional Care Team
External CCA Partners
•	Providers especially primary care
•	GSSC/LTSC
•	InstED

There is a hexagon with Care Partner RN/BHS in the center. There are arrows pointing out and in, indicating a back and forth relationship with Community RN, Community LPN, two Community HOWs, Community APC, Community BHS, and Community APC.

Internal CCA Partners
•	ED2Home
•	Transition of Care
•	Palliative Care
•	Health Education Team
•	PCA Team
•	UM
•	Fulfillment
•	Rehab
•	Admin
•	CPU
•	CRU
•	Onboarding