a. CP Composition
i. High-level description of the Affiliated Partners that comprise the CAWM
The Care Alliance of Western MA is comprised of seven non-profit organizations located throughout western MA. Its lead agency is WestMass ElderCare, Inc. The CAWM has formed a legal partnership for the purpose of contracting with EOHHS to provide LTSS CP services. Each of the partners has the long-term experience and expertise to provide LTSS CP services to the population:
Description of the partners is as follows:
1. WestMass ElderCare, Inc. – Lead Agency WestMass ElderCare, Inc. is a private, non-profit agency incorporated in 1974. WMEC is designated as an Aging Services Access Point by the Massachusetts Executive Office of Elder Affairs and an Area Agency on Aging by the United States Administration on Community Living. WMEC provides a variety of community-based services throughout western Massachusetts.
WestMass ElderCare’s Goals are formalized in the Area Plan, which is approved by the Massachusetts Executive Office of Elder Affairs:
• Promote and support the strengthening of comprehensive and coordinated community based service systems to ensure that such services are available, accessible and acceptable to older persons and persons with disabilities.
• Develop and implement new strategies for more effectively targeting resources and programs for the needs of the most vulnerable, with special emphasis on low-income minority individuals and caregivers.
• Promote the recognition of the importance and the development of preventative in-home and community-based supportive services as vital components of the Continuum of Care (i.e. prevention and alternatives to institutional care.)
• Develop and implement strategies for strengthening the family and interdependence of generations.
• Promote the recognition of elders and people with disabilities as a resource to themselves, to their community, and to the nation
. • Preparing for tomorrow: Increase awareness of the challenges and opportunities presented by the growing number of elders and people with disabilities in our society through public information.
These goals are based upon unmet needs in our region, determined through periodic Needs Assessments conducted by WestMass ElderCare. Progress towards meeting our Area Plan goals and objectives is measured on a quarterly basis, and reported to our Board of Directors. WestMass ElderCare’s major programs and services are as follows:
• Information and Referral
• Options Counseling
• Money Follows the Person Demonstration and Transitions Coaching
• Home Care Programs, including Enhanced Community Options Program (ECOP), Congregate Housing, Supportive Housing
• Clinical Assessment and Eligibility
• Community Choices (CHOICES)
• MassHealth Adult Foster Care
• MassHealth Personal Care Management Program
• MassHealth Group Adult Foster Care 2
• Congregate and Home Delivered Meal Programs
• Caregiver Support and Community Grant Programs, including evidence-based health promotion and disease prevention services
. • Money Management Program
• Long Term Care Ombudsman Program
• Senior Care Options Geriatric Support Services Coordinator Services
• One Care Program Long Term Support and Services Coordinator Services
Care Management and Care Coordination are central to the mission of the organization, which is: “To preserve the dignity, independence and quality of life of elders and disabled persons desiring to remain within their own community.” Individuals who are referred to WestMass ElderCare for help with maintaining their independence are best served with personalized and individual attention by experienced and knowledgeable staff, who can access the agency’s and community resources as needed to assist the individual make their own informed choices about how they may maintain their independence and quality of life.
2. Greater Springfield Senior Services, Inc. is a private nonprofit organization dedicated to maintaining a quality of life for older adults, caregivers and persons with disabilities. This mission is achieved through the provision of programs and services which foster independence, dignity, safety and peace of mind. GSSSI promotes the right of all individuals to live with dignity in the setting of their choice by offering information, services, and the support needed to make informed choices which enhance well-being and independence.
3. Stavros Center for Independent Living, Inc.’s mission is to help persons with disabilities and deaf people develop the tools and skills they need to take charge of their own lives. They accomplish this through programs and services designed to meet the needs of persons of any age or disability as they work to achieve the life goals that are important to them. Real independence also means a community free of barriers, and Stavros works as advocates throughout the Pioneer Valley, across the state, and nationally to bring an end to discrimination--whether it is rooted in a set of stairs, prejudice about employment, limited access to health care, or anywhere else.
4. Behavioral Health Network, Inc. -BHN is a regional provider of comprehensive behavioral health services for adults, children and families with life challenges due to mental illness, substance abuse or intellectual and developmental disabilities.
5. Highland Valley Elder Services, Inc. Highland Valley Elder Services is a private, notfor-profit corporation serving twenty-four communities in Hampshire and Hampden Counties of western Massachusetts. HVES serves older adults and their families through collaboration, education, advocacy and a range of programs designed to support them where they live
. 6. AdLib Center for Independent Living, Inc. is a private, non-profit, community based, consumer controlled Independent Living Center. The Center provides independent living and specialized services for people with disabilities in Berkshire County. AdLib empowers people with disabilities to live more independently and have control of their own lives.
7. Elder Services of Berkshire County, Inc.’s mission is to provide Berkshire elders, caregivers, and individuals with disabilities the opportunity to live with dignity, independence, and self-determination, and to achieve the highest possible quality of life.
b. Community Partner Population Served:
i. Service Areas covered by the CAWM: Western Region Service Area and the Athol Service Area within the Central Region
ii. Demographics of the populations CAWM supports or intends to support in the Service Areas covered:
-Individuals with complex LTSS and BH needs -Individuals with brain injury or cognitive impairments
-Individuals with physical disabilities
-Individuals with Intellectual Disabilities and Developmental Disabilities (I/DD), including Autism
-Older adults (up to age 64) with LTSS needs
-Children and youth (ages 3 – 21) with LTSS needs
c. Overview of the 5-Year Business Plan
i. Long term goals The Care Alliance of Western Massachusetts’ five (5) year business plan for implementing the LTSS CP program is as follows: The mission of the Care Alliance of Western Massachusetts (CAWM) is to efficiently and effectively achieve the objectives of the Long-Term Services and Supports Community Partners Program in the four counties of Western Massachusetts and in the Athol, MA service area. The aim of the CAWM is to mitigate the divide that exists between providers of LTSS care due to lack of information sharing, coordination, and knowledge, leaving members unserved or underserved. Specifically, the CAWM has structured itself to deliver integrated LTSS care coordination that provides the:
highest quality member experience,
• is accessible to the member and the family
, • is the most appropriate level of care in the most appropriate setting (the right care at the right time in the right place)
• is person-centered,
• is efficient and non-duplicative,
• supports community-first and independent living values, and
• is culturally competent • reduces the negative impact of social determinants on enrollee health status • improves health status of enrollees
• Reduces the cost of care.
To attain these long-term goals, the CAWM must provide effective LTSS care coordination by:
• improving collaboration, communication, cooperation and understanding between ACOs, MCOs, CPs, BH, LTSS, and the physical health systems
• make investments in technology and information systems to improve the LTSS infrastructure and effectively share information with all providers of LTSS services
• install a Quality Management Program that sets specific, high and measurable quality standards for each of above stated components of optimal LTSS care coordination; manage to these standards (Expect and Inspect).
• recruit, train and retain the qualified staff to efficiently and effectively serve enrollees
ii. Anticipated challenges
The anticipated challenges include:
• Deeping relationships with each of the seven ACOs/MCOs serving Western Mass, including providing information and understanding of the services the CAWM provides to actualize our shared vision of excellence in care coordination.
• Clarifying the role of the CAWM in working with each ACO/MCO
. • Developing reports and the requisite data that meet the needs of each ACO/MCO and EOHHS and efficiently sharing this information.
iii. Sustainability Plans
The CAWM LTSS program’s sustainability is contingent on its proven value to payers and to enrollees. The resources provided under the LTSS CP initiative provides the CAWM the opportunity to improve the efficiency of the LTSS systems and improve the quality of the care coordination services being delivered. If the long-term goals are met, the program will be sustainable under a value based payment system:
• the provision of the right care at the right time in the right place
• person-centered and achieves high quality member experience
• reduction of the negative impact of social determinants on enrollee health status and improves health status of enrollees
• reduction in the cost of care Payers will make the necessary future investments in the model to sustain it.
The CAWM will use the capacity building resources allocated to the LTSS CP initiative to build a cost effective, quality program that will be sustainable throughout the contract term and beyond to build/refine an infrastructure that ensures the above goals are met.
Cost Effectiveness: The CAWM will use the DSRIP funding to develop information systems that will eliminate duplication by providers of LTSS CP services, thus reducing the cost per member to payers. Capacity building funds will be invested to develop information systems that facilitate information sharing by all those serving Assigned and Engaged Enrollees (CPS, the ACOs, MCOs, EOHHS, etc.) in an effort to eliminate duplicated service among and improve coordination between providers.
Quality: Capacity-building resources will also be invested in systems that provide electronic tracking, contract management, quality reporting, contact management with the enrollees and billing systems. Internal data sets (quality and outcome measures and metrics) will be developed to monitor and improve performance based on value-based care measures.
In addition, infrastructure resources will be used to hire and train the most skilled, culturally competent staff to operate and oversee this program, crafting and managing the continuous quality improvement program. The bidder will invest infrastructure monies in building and retaining this highly effective team.