The Brien Center’s Behavioral Health Community Partners (BH CP) Program joins an array of existing services at the Brien Center for Mental Health and Substance Abuse Services (“The Brien Center”), a community-based, non-profit agency with over a 95-year history of providing a continuum of care for children, adolescents, adults and families living with serious and persistent Behavioral Health (BH) disorders.
Each year, the Brien Center serves approximately 10,000 Berkshire County residents, including 4,000 children. The Brien Center BH CP program provides a care management program that helps persons with high behavioral health needs to discover inherent personal strengths, to develop new skill sets and knowledge about area resources, and to expand their support system.
The Brien Center’s treatment approach incorporates recovery, resiliency, and rehabilitation principles; promotes individual and family choice; is evidence based; and uses family, team, and natural supports that promote stabilization, recovery, and wellness through a person’s life journey. Our new BH CP program works closely with Brien Center programs at 27 locations throughout Berkshire County as well as area primary care physicians, Accountable Care Organizations (ACOs)/Managed Care Organizations (MCOs) and other critical community, regional and state partners to provide comprehensive health services.
CP Composition The Brien Center BH CP program does not have consortium entities or affiliated partners.
Community Partners Population Served
1. The Berkshires is unique in its’ relative geographic isolation; the service area truly stands alone. As a result, the Brien Center’s specific Service Areas will encompass all of Berkshire County, without artificially crossing a geographic barrier to the Connecticut River Valley of Western Massachusetts. The Brien Center BH CP program will serve MassHealth Enrollees in the Adams and Pittsfield Service Areas; located on the western edge of Massachusetts bordering Vermont to the north, New York to the west and Connecticut to the south. It is the second largest county by land area in the state with a total of 946 square miles of rural countryside.
2. The demographics of the populations the BH CP program will serve includes ACO and MCO-enrolled members ages 21 and older with Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD) and high service utilization. It is anticipated that the Brien Center BH CP program will receive up to 1,471 eligible enrollee referrals. . It is estimated that we will serve up to 1,025 engaged enrollees within the proposed Pittsfield and Adams Service Area by the end of BP1. We are prepared to add capacity over the Contract period. It is projected that up to 30% of the engaged enrollees will also participate in the Brien Center’s Adult Community Clinical Services (ACCS) Program through the Brien Center.
Overview of 5-Year Business Plan
The focus of the Brien Center’s BH CP Program investments and strategies will revolve around the following goals:
• Help engaged enrollees with high behavioral health needs (which may also include complex LTSS needs) and their families to help them navigate BH and Long Term Services and Support ( LTSS) care in Berkshire County
• Improve member experience, continuity and quality of care by holistically engaging members with high BH needs (SMI, SED [Serious Emotional Disturbance] and SUD) and LTSS needs
• Work closely with primary ACOs and MCOs to provide care across a continuum of care (physical health, behavioral health and community supports) to meet overall needs of BH CP enrollees
• Strengthen the BH CP infrastructure through the development of technology and information systems to assist in the sustainability of the Brien BH CP program
• Build and maintain strategic community relationships and collaborate with ACOs/MCOs and community agencies to address the social determinants of health and behavioral health, LTSS needs (as applicable) and health care delivery systems in order to break down existing silos and deliver integrated care
To support these goals, the Brien Center BH CP will revolve around long term objectives including:
1) Technology and information sharing
- Challenge: Developing Information Technology (IT) solutions to support a new EHR that will allow for the unified presentation of assessment data, person-centered care plans across BH CP, PCPs, Model A ACO Contractors and other stakeholders that support true care integration
- Solution: Support data integration through the utilization of a new EHR (“eHana”) that specializes in care management software; collaborate with ACO Partnership Plans (ACOs) to employ a single Comprehensive Assessment and person-centered care plan
2) Workforce development
- Challenges: Recruiting and retaining qualified BH CP staff to serve eligible and engaged enrollees; providing evidenced based tools to BH CP staff to appropriately engage enrollees with complex BH needs with a history of high service utilization
- Solution: Utilizing incentives (i.e. loan forgiveness through Statewide Investment opportunities) and comprehensive recruitment strategies to recruit and retain qualified BH CP staff; use evidenced based training to provide the needed tools for BH CP staff to engage eligible and engaged enrollees with high BH needs
3) Program Administration
- Challenge: Measuring how we provide integrated and timely delivery of medical and BH Care, as well as adequate psychosocial supports, to maintain members in the community
- Solution: Develop and invest in operational infrastructure of BH CP to monitor program compliance and to track outcomes related to a member’s journey through the BH CP program services. Lower than expected outcomes will allow the BH CP team to do a deep drive to address the reason for the outcomes and what system adjustments will ensure improved member outcomes.
In order for the Brien BH CP Program to work towards sustainability over the five year period, the Brien Center BH CP program will develop its proposed infrastructure, capacity building investments, and efficiency in program administration during the Contract Term and following the initial Contract Term through:
- DSRIP Dollars (initial investment and ongoing funds distribution associated with volume)
- Shared savings initiatives developed over time with the ACOs/MCOs and community agencies
- The ability to sell services to MCOs for non-CP eligible individuals who can benefit from CP services to manage the Total Cost of Care for more Enrollees
- Managing fixed costs associated with IT, licensing, fees and general expenditures over time
- Identifying and developing new services for ACO, MCO, and commercially enrolled individuals to help individuals live independently in the community, decreasing the total cost of care associated with avoidable hospital utilization.
Overall, the Brien Center BH CP Program will utilize these investments and strategies to provide, in collaboration with agency programs and community partners, a specialized and sustainable care management service supported by improved technology and well-trained staff to help persons with high behavioral health needs to stay physically and emotionally healthy and to thrive in a community setting.
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