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Baystate Health Care Alliance in Partnership with Health New England (BeHealthy Partnership)

Part 1. Executive Summary

1.1 ACO Composition and Governance Structure

The BeHealthy Partnership envisions five health centers, together as Baystate Health Care Alliance an Accountable Care Organization (ACO) , and Health New England, a Managed Care Organization (MCO), coming together to achieve sustainable delivery system transformation to improve the health and lives of our members and their community. 
 
Our BeHealthy Partnership is comprised of Health New England, the MCO, and five community health centers encompassing seven sites of care in Springfield.  Health New England is a health plan with commercial, Medicare and Medicaid members.  Health New England has worked closely with all of our partner health centers and our Medicaid leadership team members visit the health centers often and know many employees by name.  Caring Health Center, with three sites, is a Federally Qualified Health Center.  They provide adult and pediatric care, behavioral health and substance abuse treatment, and a refugee program.  The other four health centers are part of the Baystate Health system.  High Street Pediatrics is a pediatric only site which includes the 4C Program, a multidisciplinary care team designed to meet the needs of the most medically complex children.  High Street Adult is a health center serving adult patients only and is a teaching site for Baystate Health residencies.  Brightwood and Mason Square health centers care for adults and children.  All of our health centers are safety net providers with MassHealth as the payer for most patients.  All of the health centers have some experience with team based care and population health initiatives.  All are excited and energized by the possibilities for improving care within the BeHealthy Partnership. 
 
The Baystate Health Care Alliance ACO is governed by a Board of Managers comprised of 75% providers of care, a community representative and administrators.  Baystate Health Care Alliance together with Health New England representation have a Joint Operating Committee with a cadre of subcommittees including Quality, Clinical, Financial and Data Analysis that drive the operations and support DSRIP investments/DSRIP related decision making for the  BeHealthy Partnership. 

1.2 ACO Population Served

The BeHealthy Partnership will serve 39,204 members throughout the Pioneer Valley in Western Massachusetts comprised of the Springfield, Holyoke, Northampton and Westfield Service Areas. 

A majority of the individuals served by the participating health centers have MassHealth. They represent a diverse population, including refugees, homeless individuals and pockets of high concentrations of different ethnic groups. The individuals served by the health centers is similar to the break-downs for the City of Springfield.

In terms of Massachusetts County Health rankings, Hampden County ranks last in the state for both health outcomes and health factors. The city of Springfield as well as Hampden County as a whole has more racial and ethnic diversity than the rest of Western Massachusetts and many other parts of the state. In fact, the majority of Springfield neighborhoods fall under the Urban Institute’s category of “majority minority”: people of color account for the majority (66 percent) of Springfield’s population with an estimated 43 percent of the city’s population being Latino, 19 percent Black, and 2 percent Asian. For school-age children, children of color represent an even greater proportion of the population with 62 percent Latino, 20 percent Black and 3 percent Asian according to the Massachusetts Department of Elementary and Secondary Education.i  County-wide, 22 percent of the population is Latino, 9 percent is Black and 2 percent is Asian,ii though this diversity is not equally spread throughout the region and tends to be concentrated in the urban core. The median age for this area is similar to that of Massachusetts, though the population over 45 years old is growing as a percentage of the total population. Chronic health conditions – High rates of obesity, diabetes, cardiovascular disease, COPD, asthma, and associated morbidity impact Springfield and Hampden County residents. An estimated 30 percent of adults in the population are obese, with high rates also observed among children. iii The MDPH “Status of Childhood Weight in Massachusetts, 2011” report found that 41.8 percent of Springfield children screened were overweight or obese, which was nearly one-third higher than the state. iv Heart disease is the leading cause of death in Hampden County, and Springfield has more hospitalizations for stroke than the state average.v One third of Hampden County adults have hypertension, a risk factor for cardiovascular disease, with rates increasing in older adults to an estimated 55 percent. In addition, Springfield residents were found to have COPD rates 24 percent higher than that of the state.vi Approximately 20 percent of the population has pre-diabetes or diabetes. Additionally, 12 percent of adults and 19 percent of school children have asthma. Asthma morbidity rates were particularly high among Latinos. vii Among Springfield children, Latino and Black children were also found to experience hospitalization rates 4-7 times higher than White children. viii

Furthermore, sexually transmitted infection (STI) rates are high, with Springfield chlamydia rates almost 3 times the state and HIV rates elevated as well. Hampden County youth STI rates are particularly high with rates of chlamydia and syphilis 2-4 times higher than that of the state. Though teen pregnancy rates have decreased due to collaborative initiatives to address this issue, Hampden County teen pregnancy rates continue to be high with rates double that of the state. ix

Across Hampden County and the City of Springfield, substance use and mental health were identified as two of the top three urgent health needs impacting the area in interviews with local and regional public health and in the Springfield community performed as part of the 2016 Community Health Needs Assessment (CHNA). Emergency Room visit rates for mental disorders in Hampden County in 2012 were 24 percent higher than that of the state. Among all Hampden County communities in 2013, Holyoke and Springfield had the highest rates, with rates in 2012 80-85 percent higher than the state.x Using MDPH 2009-2011 hospitalization data, one report found that Springfield residents experience more than double the rate of age-adjusted hospitalizations due to mental health conditions than that of the state overall (1950 versus 865 per 100,000 population).xi

Substance use disorders overall (including alcohol) and opioid use were of particular concern. Opioid use disorder, which has been declared a public health emergency in Massachusetts, is impacting Hampden County residents with fatality rates higher than that of the state. Tobacco use remains high with an estimated 21 percent of adults who smoke. Youth substance use is also an issue with 15 percent of Springfield 8th grade students reporting drinking alcohol in the past 30 days and 12 percent using marijuana.

The need for Long Term Supports and Services in Springfield and Hampden County is great and growing. Approximately 19 percent of the city population is disabled (over 28,000 people).xii Additionally, older adults in the Hampden County area are increasing in number and have a high incidence of functional impairment, a heavy burden of chronic disease and limited socioeconomic resources. For example, 64 percent of Springfield older adults have four or more chronic diseases and only 7 percent have no chronic conditions. 17 percent of Springfield residents over the age of 65 have Alzheimer’s disease or related dementias per reported statisticsxiii, but this is likely a gross underestimate of the magnitude of the problem since so many patients are undiagnosed.

Lack of resources to meet basic needs – Many residents in our service area struggle with poverty and low levels of income. Across Western Massachusetts, 16 percent of residents live in poverty, and the median family income in three of the four counties is more than 20 percent lower than that of the state. Child poverty rates are high with 23 percent of children in our service area living in poverty. Hampden County has the highest rates of poverty and unemployment in our service area and the lowest median income.

Housing needs – Housing insecurity is a need that impacts our population. Almost one third of the population is housing cost burdened, with over 30 percent of their income going towards housing. Although overall homelessness has decreased in Western Massachusetts, the number of homeless families has increased in the region.

Transportation - Regional public health officials interviewed for the 2016 CHNA identified increased transportation options as an overall community need for the region as a whole, and specifically for rural low-income populations. Individuals who do not own a vehicle face difficulties accessing educational and employment options, community-based programs that promote health, such as exercise and nutrition programs, and other activities that promote social connection.

Lack of community safety – Lack of community safety was identified as a prioritized health need because of the high rates of crime in parts of our service area. In particular, crime rates are high in Hampden County, with violent crime rates almost 50 percent higher than that of the state.

Food insecurity and food deserts – Food insecurity impacts the ability of many residents in our service area to access food overall, including food that promotes good health. Each county of Western Massachusetts counties has communities that experience high rates of food insecurity with rates over 20 percent found in areas of Amherst, Chicopee, Holyoke, Montague, Northampton, Springfield, Ware, and West Springfield. In addition, some communities in Western Massachusetts are also considered food deserts, which are areas where low-income people have limited access to grocery stores. There are food deserts scattered around the region, including in portions of Orange, Turner Falls, Amherst, Northampton, Palmer, Chicopee, Holyoke, Springfield, West Springfield, Agawam, and Westfield.

Environmental concerns - Air pollution impacts the Western Massachusetts region as a whole, but has a particular impact on the health in Hampden County. Springfield experiences poor ambient air quality due to multiple mobile and point sources. Near roadway air pollution impacts the community members that live, work or attend school in close proximity to the highway. Air pollution impacts morbidity of several chronic diseases that have a high prevalence in Hampden County, including asthma, cardiovascular disease, and diabetes.

Institutional racism – Institutional racism was identified as a health need for our population because of the impact it has on racial and ethnic health disparities found in Hampden County and across the region. Large racial and ethnic disparities in health outcomes were found across a number of health concerns. Institutional racism has been defined as racial inequities in access to goods, services, and opportunities such as quality education, housing, employment opportunities, medical care and facilities, and a healthy physical environment. In particular, the connection between racial residential segregation and low levels of opportunity in communities of color was identified as one form of institutional racism that impacts health. The Springfield Metropolitan Statistical Area, which includes Hampden, Hampshire and Franklin Counties, was identified as the most segregated in the U.S. for Latinos and 22nd most segregated for Black or African-Americans in an analysis conducted by the University of Michigan. 

1.3 Overview of DSRIP Investment Approach

The health centers in the ACO partner and the MCO have agreed on an ideal model of care. Our model moves us from physician based care to team based care, centered on the patient’s goals.  We will invest in community health workers to enhance teams which currently include physicians, mid-levels, nurses and medical assistants. We will support translation services to better serve our members who speak over forty languages, integrate behavioral health and substance use disorder treatment into primary care to the maximum extent possible, and deliver care to members where they need and want their care. We will address the social determinants of health, partnering with community resources to more fully support our members and seek resources to allow us to be as culturally and linguistically appropriate as possible for our very diverse patient population.  Provider accountability is best achieved in a new payment model. We have agreed that our model would be best supported by a global payment for primary care services, allowing all team members to operate at the top of their license and giving room for creative approaches to health education and care delivery which will include full participation by team members not reimbursed in a traditional fee for service model, such as community health workers and medical assistants.

We expect the results of our delivery system redesign/total cost of care management, combined with ACO level resources for transitions of care and complex member management, to result in reductions in avoidable costs of care and increases in member engagement and quality of life. Sustainability will be achieved through a savings from the risk model and outside grant funds.

The goals for the ACO include a reduction in admissions, reduction in emergency room usage, expansion of primary care services, integration of behavioral health & substance use with primary care, engaging members in new ways, advancing clinical interoperability and improving quality.

We have a team of clinical leaders representing all five health centers plus the MCO who meet regularly. After agreeing on the clinical model and ideal payment model, we considered challenges/barriers to achieving our goal. Identified barriers include professional training and work expectations which do not align with new models; patient expectations for traditional care delivery; regulatory barriers; physical space in the health centers which is not suited for group visits, team meetings and telehealth; and compensation incentives which do not align with our delivery system vision. We will be tackling these barriers immediately and will seek out the experiences of other health systems engaging in this endeavor. We expect to invest in training, patient education, and support for utilizing alternative sites of care. We know that all of our efforts need to be informed by timely, accurate and integrated data.  We will be investing in developing a health information technology infrastructure to support our efforts. 

1.4 Website

The URL to the ACO website is the following:    www.BeHealthyPartnership.org 

i Partners for a Healthier Community, Springfield Health Equity Report, October 2014
ii US Census Bureau, American Community Survey (ACS), 2010-2014
iii BRFSS, 2011
iv PHC, October 2014
v MDPH, Massachusetts Deaths 2013
vi PHC, October 2014
vii BRFSS, 2011
viii PHC, October 2014
ix MDPH, 2012, 2014; CDC 2013 x MPDH, 2012-2013
xi PHC, October 2014
xii ACS, 2010-2014
xiii Massachusetts Healthy Aging Collaborative. Massachusetts Healthy Aging Community Data Profile: Springfield, 2014. 

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