Lahey Health Behavioral Services (LHBS) as a Community Partner (CP) program hopes to improve the lives, health and well-being of individuals with SMI and/or SUD, as part of the MassHealth system transformation. We will leverage our 60 years of experience as an innovative provider organization to charter this new course in care delivery on behalf of MassHealth members.
The current healthcare system does not work well for adults with high Behavioral Health (BH) needs and lacks the very supports such as care coordination and care transitions that are so critical to outcomes of both cost and quality. High rates of mortality and morbidity, and poor health outcomes indicate a poor use of resources. Further, many of our members with high BH needs experience a range of adverse, economic, social and environmental conditions that weigh negatively upon health and functional outcomes.
As a CP, we will be able to address the full range of needs that MassHealth members face. That includes medical, behavioral health, long-term services and supports and the social determinants of health. With DSRIP funds, we will leverage our previous experience to build a solid program based on emerging and evidence-based practices, and hire a diverse care team with the expertise and the experience needed to provide supports in a personcentered, yet culturally and linguistically competent manner.
Enrollees, Service Areas, and Timeframes
LHBS plans to serve 1,600 MassHealth enrollees and to operate and provide services and supports to all 9 service areas in MassHealth’s northeast region, including Beverly, Gloucester, Haverhill, Lawrence, Lowell, Lynn, Malden, Salem and Woburn. LHBS will comply with all EOHHS requirements to operationalize the CP program and implementing such supports and activities.
Goals, Challenges, Solutions
LHBS has outlined its goals and related challenges and offers several solutions to the challenges in Table 1 below. We will continually work to address these challenges over the 5 year contract term.
Table 1: LHBS Goals, Challenges, and Proposed Solutions
| Goal | Description of Goal, and Related Challenges |
|---|---|
| Goal 1. Relationships | Challenge: The current healthcare, BH and social service system is fragmented and both members and providers do not know who to go to for answers or resources. Forming relationships across settings is not easy given resistance and competing priorities. Goal: LHBS will create strong relationships with members, ACOs, MCOs, providers, independent living centers, recovery living centers, communities, housing agencies, food banks, police stations, and others to facilitate success as a CP and to meet members’ needs. We will also leverage information technology solutions to support these relationships. Proposed Solution(s): We will emphasize frequent communication with all appropriate community and provider stakeholders regarding member care, and will continually educate community organizations about our role and value. We will leverage information technology (IT) solutions as necessary to meet these goals. |
| Goal 2. Workforce | Challenge: The BH CP program success is highly dependent on recruiting and retaining the right people in a highly competitive market. Goal: LHBS will create a strong workforce of care coordinators, care managers, community health workers, and any other categories needed to implement program and meet the needs of our members. Proposed Solution(s): LHBS will dedicate an FTE from our talent acquisition team who will be responsible for recruiting candidates for the BHCP. LHBS will transition the teams from care coordination programs that have ended (CHART and Here-For-You) to the BHCP. Ramp-up period includes planning for recruitment. |
| Goal 3. Protocols/Tools Process. | Challenge: LHBS needs to ensure consistency and effectiveness across the CP program and with other providers (ACOs and MCOs) to deliver high-quality, accountable care in challenging circumstances. Goal: We intend to deliver consistently excellent care to our members to demonstrate the value to EOHHS and the ACO and MCO partners. Proposed Solution(s): LHBS will leverage our existing protocols, processes and tools to support the implementation of CP services and supports and to achieve the intended outcomes. We will continually search for ways to improve our processes to align with best practices and evidencebased care guidelines. |
| Goal 4 LTSS | Challenge: Integrated care management for members who have BH and LTSS needs can be challenging. Goal: LHBS will bring best practices to serving all BH CP assigned and engaged enrollees with LTSS needs. Proposed Solution(s): We will leverage our experience and relationships with organizations in the community to implement an LTSS management program that is responsive to members’ individual needs, inclusive of best practices and financially responsible. |
| Goal 5. Value Proposition | Challenge: Sustainability of the CP program beyond the 5-year contract requires demonstrating value proposition to ACOs, MCOs and other providers. Goal: LHBS will maximize performance on quality, cost and member experience metrics to demonstrate value. Proposed Solution(s): We will work with ACOs and MCOs and other providers during the 5 years to establish a framework and conduct an analysis of the data to demonstrate our value. |
Supporting Populations and Community Engagement
LHBS knows that the best way to support our members is to engage the communities in which they live, eat, pray, work, socialize and get care. At the same time, understanding the culture, the strengths and the barriers that members face helps identify and meet the needs in a person-centered manner. LHBS has well-established connections to the community and will grow these connections to the community to serve the person-centered needs of our assigned and engaged enrollees. We will ensure that staff is informed of community resources over the course of the contract term and beyond. We will meet all requirements Model Contract to build all required community collaborations and coordination.
Connections to the Community For 60 years, LHBS has been a community provider of a robust continuum of BH services in the northern region in the communities and service areas in which we propose to operate as a CP. LHBS has a strong footing throughout the northern region, where we provide services to MassHealth members with BH needs, and where we have developed collaborative relationships with other community-based providers, social service organizations, housing/shelter providers and social service organizations. We currently provide services to members in all service areas. We are a Community Service Agency (CSA) for Cape Ann and Haverhill. We operate three Emergency Services Programs (ESPs) in four locations in Salem, Haverhill, and Lawrence, serving 37 cities and towns collectively. Our CSP, HFY and CHART care coordinators have developed processes for referral and coordination with a broad array of service providers in order to meet the unique needs of our members. In addition, we have established relationships with housing agencies, fuel assistance programs, faith-based and social-service organizations, in addition to state agencies.
As a CP, we will grow these links to the communities in all nine service areas within the northern region to ensure that we are have the connections to address the needs of our enrollees, including those needs that are identified in the person assessment and treatment plan and to support the enrollee’s health and well-being. Building a strong system of connections is critical to our ability to meet our enrollee needs for community-based social services and flexible services.
See Table 2 for an overview of our current connections to the community by the areas of needs.
Table 2: List of Current Connections to the Community
| Area of Need | Active Relationships in all 9 services areas in the Northeast region |
|---|---|
| State Agencies | Department of Mental Health (DMH), Department of Children and Family (DCF), Department of Youth Services (DYS), Department of Developmental Services (DDS), Department of Early and Secondary Education (DESE), DPH |
| Local/Municipalities | All city and towns within the service areas |
| Housing | Shelters, housing support programs, Local public housing entities |
| Education | Schools, universities |
| Health Care | Primary care providers, local chapters, community hospitals, urgent care centers |
| Community-based Organizations | Recovery Learning Communities (RLCs), Independent Living Centers (ILCs), Clubhouses, local chapters of NAMI, YMCAs, faith based groups |
| Law Enforcement | Local police departments, court clinics |
Plans to Grow Connections and to Keep Staff Informed of Community Resources
LHBS is in the process of developing protocols to grow both our relationships with community organizations and our staff knowledge about the resources available in our communities to meet member needs, and the needs we anticipate in our CP assigned and engaged members. Through our experience with members with SMI and SUD, we have learned that diverse engagement strategies are needed to achieve the goals and the vital importance of close coordination between care providers and supportive community resources in achieving treatment goals and preventing relapse. The dramatic ramp-up of our care coordination program from the HFY portfolio will necessitate that we expand our network consciously to meet the new needs.
We will pursue several strategies to both strengthen and expand our community connectedness:
1. Relationships with Care Coordinators: Our care coordinators will be on the frontlines of efforts to identify new partners in the communities driven by the needs of individual members. Themselves members of the communities in which we work, we will leverage the personal and professional connections of our new staff to build trusting relationships with community partners.
2. Expanded resource manual of community resources: To make sure all new and existing staff are aware of the resources and partnerships we have in the community, we will make expand our current resource manual to include the range of community resources needed by our members.
3. Identify gaps in our community partnerships: As care coordinators and other staff identify gaps in the community resources available within our manual, we will document these gaps and work diligently to identify new partners to meet needs.
4. Work closely with SMI and SUD-focused organizations: Given their central role in advocacy and service delivery for our target populations, we will coordinate closely with Independent Learning Centers (ILCs) and Recovery Learning Centers to coordinate care for members and ensure our programs are accountable to their expectations on a macro level.
Table 3 below provides an overview of our community connections, specific to members with SUD.
Table 3: Community Connections Specific to Members with SUD
| # | Description of Connection |
|---|---|
| 1 | On our Danvers campus, we offer the evidence-based Allies in Recovery (AiR) program to assist families to understand addiction and learn behavioral strategies to support family members with addictive disorders. |
| 2 | We actively participate in the Danvers and Gloucester Prevention Coalitions, as well as participate in the multi-agency group in Gloucester focused on identifying and coordinating care for high risk persons in the community with acute and chronic behavioral health disorders. We have developed relationships with local police departments to expedite treatment access. Burlington and Tewksbury Police Departments work closely with our detoxification program in Tewksbury to admit individuals. Additionally, LHBS has a clinician embedded in the Danvers Police Department and fiscally and clinically supports a master’s level clinician working with the Gloucester Police Assisted Addiction and Recovery Initiative (PAARI). |
| 3 | All programs provide overdose prevention education and have overdose prevention plans for the program itself, as well as individualized plans for the people we serve, including providing access to the lifesaving medication naloxone. |