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Community Care Partners, LLC.

Executive Summary

a. CP Composition

Community Care Partners (CCP) is a Limited Liability Corporation formed by Bay Cove Human Services (Bay Cove) and Vinfen Corporation (Vinfen) in May 2017 to provide Behavioral Health Community Partner (BH CP) Services in the Greater Boston, South and North regions. Bay Cove, Vinfen and Bridgewell, are Member Organizations of CCP. The broader MassHealth Delivery Reform effort and the Community Partner (CP) Program initiatives promise to strengthen and progress the landscape of care delivery and support for people with Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD) in a manner that all three Member Organizations fully support.

CCP is committed to the integration of behavioral health (BH), medical and long-term support services (LTSS) to better serve people with SMI/SUD. Each Member Organization has over four decades of experience serving the diverse healthcare and social support needs of this complex population. Further demonstrating its industry experience, CCP’s Member Organizations have annual operating budgets adding up to nearly $320 million, employ over 5,800 staff, and serve over 36,000 people in Eastern Massachusetts. Together, these organizations provide a comprehensive set of community-based mental health, behavioral health and substance use treatment services, including:

• Seven outpatient mental health clinics and two-day treatment programs

• Crisis stabilization units (a less costly alternative to inpatient psychiatric hospitalizations) and staffing of several emergency services programs

• Detoxification programs, transitional support services, recovery homes and medication assisted treatment for people with SUD

• Specialized outreach, shelter and day programs for people with SMI/SUD who are homeless

Vinfen and Bay Cove have provided outreach and care coordination services for 3,500 people with serious mental illness through the Department of Mental Health’s (DMH) Community Based Flexible Support (CBFS) program. Both providers are also One Care Health Homes serving over 500 people in this integrated care management program for BH, medical and LTSS.

Each organization is a leader in its local communities and in its field of service. Bay Cove is one of the state’s premier SUD providers with a full continuum of care for people with addictions. With blended expertise in SMI and SUD, Bay Cove has a reputable track record of meeting the most challenging needs of people with dual diagnoses in the Commonwealth. Vinfen is the largest DMH contractor and CBFS provider in Massachusetts and is known for its adherence to recovery and rehabilitation-based services, adoption of evidence-based practices, and technology innovation. Bridgewell is a major outpatient mental health provider in the Northern region with four practices and is known as an innovator in SUD programs, embedding Recovery Coaches in a local hospital emergency rooms to engage people who have overdosed.

Together, these Member Organizations have a presence in most communities in Eastern Massachusetts including relationships with social service providers, hospital systems, local government, police and BH providers. This local presence is the foundation for developing locally based Care Teams that will perform the functions of the BH CP program. CCP is committed to the integration of BH, medical and LTSS to better serve people with SMI/SUD and recognizes that to be effective, the core BH CP services must be provided in close partnerships with ACO/MCOs. As a result, CCP will invest considerable staff resources to develop ACO collaborations to coordinate care, reduce duplication of services, and target limited resources to the right Enrollees at the right time. CCP looks forward to planning these collaborations over the coming months.

b. Community Partners Population Served

Through its Member Organizations, CCP has a presence, provides services and supports and community connections in the following Service Areas:

• Greater Boston: Boston, Revere, Somerville and Quincy

• North: Haverhill, Lawrence, Lowell, Lynn, Malden and Salem

• South: Attleboro, Barnstable, Brockton, Fall River, Falmouth, New Bedford, Orleans, Plymouth, Taunton and Wareham

Each CCP Member Organization has over four decades of experience serving people with Serious Mental Illness (SMI) and people with Substance Use Disorders (SUD). As such, each has extensive histories developing and providing innovative and effective services for this target population. We intend to leverage this expertise and experience to support people with SMI and SUD through the implementation of the Behavioral Health Community Partner Program (BH CP Program).

Our BH CP Program will support adults between the ages of 21 and 64 of diverse cultural, linguistic, racial, ethnic and religious backgrounds and many of whom are homeless. Care Teams will serve people with a range of complex mental health, medical, developmental, neurological, and substance use disorders, along with persistent behavioral and risk issues such as problematic sexual behaviors, sexual offending, violence and aggression, antisocial behaviors, fire-setting, severe suicidality, victimization, and/or harm to self or others. In that many of these medical and behavioral complexities have created functional limitations for people that require LTSS, our care model will support people with LTSS needs as well.

c. Overview of Five-Year Business Plan

CCP has created a five-year business plan that will allow it to build the infrastructure and systems needed to serve nearly 5,000 people when at full capacity. The capacities and infrastructure that the organization develops will serve to sustain the program throughout the five-year Contract Term and thereafter. The long-term goals are outlined below:

• Implement Care Coordination Information Technology System to support Care Coordinators and Clinical Care Managers. CCP is one of five BH CPs that is using the Care Navigator system for documentation and coordination of activities. To support Care Teams, CCP will also subscribe to a service to bring in Admissions/Discharge/Transfer (ADT) data so that Care Coordinators can support Enrollees in times of transition.

• Develop system to support communication among Member Organizations: CCP will set up and maintain a SharePoint site for sharing information across Member Organizations that will be separate from Care Navigator and include information on ACO/MCO provider networks, points of contact at primary care practices, LTSS provider network and local social services providers.

• Recruit and staff for regional BH CP Care Teams: CCP Member Organizations are actively recruiting for Care Coordinators and Clinical Care Managers. Our goal is to have a skilled and caring workforce in place that has both the heart and skills to serve people with SMI and/or SUD. We will use a range of recruiting strategies to attract high quality candidates including financial incentives and advertising.

Ongoing training and learning: CCP will develop a robust training program leveraging subject matter experts across Member Organizations and making use of MassHealth trainings as needed. In addition, CCP will establish Learning Collaboratives for Care Team staff and supervisors to support ongoing learning, process improvements and share best practices.

• Care Teams that interface with ACO provider practices: CCP recognizes that, to be effective, the core BH CP services must be provided in close partnership with ACO/MCOs, the entities at risk for Total Cost of Care in the new MassHealth delivery system. As a result, CCP will invest considerable staff resources to develop ACO collaborations to coordinate care, reduce duplication of services, and target resources to the right Enrollees at the right time.

• Develop highly effective strategies for engaging Enrollees: A key focus of CCP will be on Enrollee engagement. Many people with SMI/SUD have never been enrolled in outreach or care coordination programs before and may be hesitant to participate. Without engagement, the rest of the BH CP support services cannot be of benefit. CCP will create an Enrollee Engagement Library of best practices, it will be an important principle of training for Care Coordinators and Clinical Care Managers, and it will be infused throughout the Learning Collaborative that will be created. Enrollee engagement will also be the focus of CCP’s Quality Improvement program in the first year of the program.

• Establish a management team for overseeing administrative processes, IT systems, data, quality management, financial services and analysis: CCP is building a small management company to oversee all administrative processes of the CP program.

The challenges that CCP faces in implementing this program are common across all Community Partners and fall into the major categories of systems change and workforce development. CCP fully supports the system changes that MassHealth is making through its delivery reform initiatives and the CP program. CCP believes that the breadth and scale of reforms is necessary to achieve better care and improved outcomes for people with SMI/SUD. People with SMI/SUD face significant barriers to accessing healthcare services and to partnering with their healthcare providers that the BH CP program promises to address.

At the same time, change at this scale is not easy and will require thousands of people who comprise the healthcare delivery system in Massachusetts to learn to work together in new ways. People who have not communicated before will now need to collaborate to serve people with SMI and SUD. Systems change requires the implementation of new processes, new communication methods, new data systems and good will. New relationships and ways of working will need to be developed and will impact people staffing emergency rooms, primary care offices, BH clinics, state agencies, human services organizations and others. CCP understands the challenges it faces and is committed to building new relationships and collaborations at the highest levels of leadership.

A second major challenge is workforce development. ACOs, MCOs, and human services providers, including CPs, are all recruiting for management teams, care coordinators and clinicians dedicated to integrated care and working with people with high needs and high costs. Finding the workforce needed to implement system delivery reforms will be challenging. Human services providers are facing additional challenges because salaries are often lower than hospital-based providers.


CCP is using DSRIP funds to develop important capacities and infrastructure necessary to operate a BH CP program. The capacities and infrastructure that the organization develops will serve to sustain the program throughout the five-year Contract Term and thereafter.

Tangible investments include a system to support care coordination as well as marketing, including a website.

Capacity investments include a workforce that is trained in Care Coordination and workflows for coordinating care across systems of care. Sustainability of the BH CP program beyond the Contract Term will ultimately depend on our relationship with ACO/MCOs and whether the services that we provide lead to better health outcomes at reduced costs. We plan to demonstrate our value along with a reduction of total medical expense to the ACO/MCOs so that they will invest in this service moving forward.

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