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North Region LTSS Partnership

Executive Summary


Greater Lynn Senior Services, Inc., in concert with its Affiliated Partners -- Bridgewell, Inc. and Northeast Arc, Inc. has formed a collaborative called the North Region LTSS Partnership (NRLP), through which it will provide LTSS Community Partnership supports for consumers in all service areas of the MCO Northern region. NRLP will provide LTSS supports to eligible MassHealth enrollees throughout the entire “North” MCO region which includes all communities comprising the service areas of: Beverly, Gloucester, Haverhill, Lawrence, Lowell, Lynn, Malden, Salem and Woburn, 

The NRLP offers deep experience in the delivery of LTSS services across the MCO Northern Region, its constituent organizations sharing: 1) deep commitment to – and success in – actualizing the principles of Community First; 2) an extensive familiarity with the diverse populations and community contexts each serves; and 3) the best practices required to optimally address specific consumer needs and preferences in order to promote better health, well-being, and meaningful independence. Additionally, NRLP’s capabilities reflect the integration of each member’s expertise, so that the NRLP can deliver best practice conflict-free case coordination, person-centered care planning and implementation, integration of disparate and sometimes overlooked community resources based on effective analytics around resource impact including performance and capabilities of LTSS providers, meaningful consumer engagement, quality improvement, multi-sectored and trans-disciplinary partnerships, and innovations that creatively and cost-effectively foster health and wellness.

The NRLP has designated GLSS-MSO,1 a newly incorporated2 wholly-owned subsidiary corporation of GLSS, to serve as the NRLP’s management services organization and provide central infrastructure support. An NRLP Executive Committee -- comprising the Chief Executive Officers of GLSS, Bridgewell, and NeArc with appropriate support from the GLSSMSO will, in accordance with a fully executed Memorandum of Agreement, oversee development and implementation of policies, procedures, overall practice and associated risks for all facets of NRLP’s operations. Member organizations will also provide Subject Matter Expertise about the consumers and communities they serve in an ongoing way through multiple avenues including: developing and implementing LTSS Coordination performance standards, providing regular trainings, supporting efforts around stakeholder engagement, and participating in the review of analytics.

The GLSS-MSO will develop and facilitate implementation of a collaborative campaign designed to sustain the requisite cultural changes across the member entities for ensuring optimal LTSS CP operations. The centralized and continuing training and learning collaborative opportunities will also foster consistent best practice performance of the LTSS Coordination function, while the comprehensive communications, data capture and analytics capacity will promote a clear and uniform focus on impact and cost-efficiency.


The NRLP serves the entire North Region, and with over 150 years of combined experience working with consumers with diverse needs, will provide supports to all enrollees from ages 3 to 64 within this region designated as eligible for LTSS supports. This includes:

• Individuals with complex LTSS and BH needs;

• Individuals with brain injury or cognitive impairments;

• Individuals with physical disabilities;

• Individuals with intellectual/developmental disabilities;

• Older adults (up to age 64) with LTSS needs; and

• Children and youth (ages 3-21) with LTSS needs



The principal goals for the NRLP five-year business plan are:

• To develop a comprehensive and unified LTSS Coordination capacity across the Northern region that actively promotes the Community First agenda for all Mass Health focus populations and that adheres to the values of conflict-free case management.

• To create stronger pathways and connections among community resources and services to promote greater consumer choices and easier navigation and access, eliminate silos, and support the principles of community livability for all.

• To create a strong and dynamic training system for LTSS Coordination staff that fosters best practices in the delivery of all elements of the LTSS CP function and which is fully scalable and transferrable

• To develop a robust quality management system that provides timely feedback and comprehensively supports best practice and cost-effective operations for all elements of the LTSS CP function.

• To develop seamless communication systems across LTSS providers, between LTSS providers and health providers, and with EOHHS and that meets all EOHHS requirements as stated in the Model Contract.

• To establish and effectively maintain a value-based resource and LTSS provider capacity and performance database that facilitates consumer choice and expands Community First opportunities.

• To identify, pilot, and disseminate appropriate promising technology and other innovations that support greater consumer access and choices relative to Community First and community livability principles.

• To strengthen clinical-community linkages to support better health and lower health care costs for all identified focus populations.

• To develop appropriate indicators, rigorously capture the relevant data, and consistently measure the impact of the LTSS CP function relative to consumer health behaviors, status, and health care costs.

• To fully establish the critical value-add which best-practice LTSS Coordination brings to the health care system both in its capacity to address the social determinants of health and its impact in lowering the total cost of care for the focus populations.

The key challenges which the NRLP anticipates as its five-year plan unfolds involve the following:

• Creating a uniform, dynamic, best-practice “LTSS Coordination” culture across the NRLP LTSS CP operations.

• Developing unified communications, data reporting, and data sharing system.

• Establishing a cohesive value-based system to measure LTSS provider and other community resource capacities and performance.

• Developing and implementing a “real time” quality management system

• Strengthening clinical-community linkages through comprehensive data sharing, feedback loops, and ongoing communications

• Aligning community resources to facilitate easier consumer access and navigation and ensuring that “hidden” and potentially “natural” resources are effectively identified

• Establishing critical indicators for LTSS Coordination – beyond the established slate -- that are reliable, measurable, reflect social determinants of health, and demonstrate impact.

The NRLP, using principles of intentional design, is developing solution strategies for optimal integration of LTSS and clinical health supports that include:

- Developing a uniform and truly best practice LTSS Coordination Capacity, beginning with a comprehensive training component for LTSS Coordination that includes ongoing demonstrated competencies around critical areas of expertise, such as:

  • Community First principles, Self-Determination, and the Independent Living Paradigm
  • Motivational listening, and other proven approaches to optimizing engagement and promoting consumer choice;
  • Understanding and recognizing diverse focus population characteristics and needs, including issues related to disabilities, chronic diseases, behavioral health, and co-morbidities;
  • Effectively identifying and aptly tailoring person-centered/person-driven supports in accordance with consumer needs and preferences;
  • Recognizing and responding to community diversity and context issues; o Delivering conflict-free case management;
  • Developing fully person-driven care planning, implementation, and monitoring;
  • Practicing principles of value-based referrals; o Monitoring social determinant of health and other related quality measures and continuously integrating these into a dynamic person-centered care plan;
  • Delivering proactive health and wellness coaching;
  • Preparing for and effectively supporting care transitions;
  • Promoting overall community livability;
  • Managing data and documentation, including properly adhering to all documented processes and their variations across ACO/MCO partners
  • Using analytics to inform Coordination process

- Establishing comprehensive workflows, policies and protocols, and key program objectives in tandem with quality management systems that generate opportunities for real time analysis and ensure QM is fully integrated into all aspects of NRLP operations.

- Fully operationalizing Thrasys/Syntranet communications and data systems that features a meaningful use certified EHR inter-operable platform to utilize capacities of existing NRLP partner systems; ensure appropriate communications with ACOs, health and behavioral health providers, social service providers; and EOHHS to support and facilitate overall NRLP functions.

- Piloting an After-Hours Call Center to support LTSS functions – facilitating greater consumer access, providing “reminder” calls, etc. to avoid missed appointments, and connecting better with afternoon/evening shift providers to better align community resources.

- Methodically expanding Kiosks for Living Well – inclusive of eTools – throughout the North region to support health and wellness coaching, build stronger clinical-community 4 linkages, sustained consumer engagement, and improved consumer health outcomes, and pilot critical new interventions

- Rigorous collecting and effectively integrating clinical and LTSS/social determinant data to deliver analytics that accurately identify and appropriately target key health and wellness interventions in ways that appropriately assess impact as well as reveal promising prevention opportunities.


We expect to effectively demonstrate the value of the specific NRLP brand to ACO/MCO partners through comprehensive collaborations, communications, and clearly defined metrics and analytics, offering clear evidence that NRLP services substantively improve enrollee health outcomes and reduce health care costs. Among the elements most critical to the brand are: a comprehensive and enhanced LTSS coordination model based on integrated partner expertise and continuous training; expansive and accessible centralized inventory of community tools and resources for promoting enrollee health and well-being; innovative community interventions, including Kiosks for Living Well that effectively promote enrollee engagement around health and well-being through a variety of support programs and technologies (including the potential for some telemedicine options); cutting-edge EHR platforms and data exchange mechanisms; communications systems and protocols that support critical workflows and decision making; and ongoing analytics promoting quality management and improvement.

The NRLP recognizes long-term sustainability requires that LTSS services are appropriately integrated within payor payment methodologies. While the improved health and well-being of enrollees – and the improved community livability that this implies – is the ultimate shared goal across our ACO/MCO partnerships, the dominant metrics for payor partners weighing the value which NRLP ultimately brings to the table will reflect levels and nature of cost savings related to patient care. Consequently, NRLP will work intentionally and transparently with its clinical and community partners to ensure that this is indeed among the benefits we deliver. Further appreciating the sensitive relationship between volume and revenue, the NRLP has targeted its infrastructure development so that we consistently offer an LTSS model that reflects both best practice as well as cost-efficiencies.

Although primarily focusing on effective management within our MassHealth ACO partnerships, the NRLP also anticipates developing the capacities to provide services to additional payors both within and beyond the current service region. Consequently, the NRLP hopes to attract investments from – and develop collaborations with – other public and private partners, thereby diversifying revenue as well as product streams. Examples of such efforts would include training, analytics, and community-based interventions including programmatic and technology innovations related to the Kiosks for Living well and its associated components.


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