a. CP Composition
i. A high-level description of the Consortium Entities and Affiliated Partners that comprise the CP.
N/A – CCBC is the sole provider of the BH CP services. There are no Consortium Entities or Affiliated Partners that comprise the CP.
b. Community Partners Population Served
i. List the Service Areas covered by the CP. CCBC’s Behavioral Health Community Partner program will serve the service areas in and around the communities of Taunton, Attleboro and Brockton. b. ii. Describe the demographics of the populations the CP supports or intends to support in the Service Areas covered. Taunton, Brockton and Attleboro: CCBC has been delivering community-based mental health and substance use disorder services in these three Service Areas for over 45 years and has developed close working relationships with many of the social service agencies in all three communities. CCBC is familiar with the cultural and linguistic diversity: high concentrations of Cape Verdeans in Brockton and Taunton, and a growing Asian population in Attleboro and Brockton. Brockton, Taunton and Attleboro have populations of those of African American decent of 32%, 5% and 2% respectively current CCBC staffing in these communities reflect this diversity. The unemployment rate in Brockton remains significantly higher than the state average.
Taunton, Brockton and Attleboro are urban communities in Southeastern Massachusetts that have been slow to recover from the economic downturns in the past 40 years. The CCBC CP target population includes the homeless population, veterans, persons with HIV, those with severe and persistent mental illness and opiate users, who all have disproportionately high percentages of mental illness and substance use disorders. Over the past 30 years, CCBC has strengthened connections to these communities and will continue to grow as a BH CP. CCBC has a host of key collaborations that will be integrated with the BH CP care coordination activities:
• Greater Bristol County/Attleboro/Taunton Coalition to End Homelessness.
• Taunton Mayor’s Office. CCBC participates in the Mayor’s Opiate and Substance Use Task Force focusing on the reduction of opioid overdoses and participates in a host of community education and prevention programs that will be a resource for the BH CP population with substance use disorders or at risk of disorders.
• The regional Prevention and Wellness Task Force Community Health Network Area 24 convened by DPH. • Attleboro YMCA and the Old Colony YMCA.
• Community Crisis Intervention Team. Over the past 10 years in partnership with the Taunton, Attleboro and Brockton Police Departments, CCBC has trained 600 police officers, with a major focus on Attleboro and Taunton police, probation officers and other 2 human service professionals in understanding serious mental illness and effective crisis intervention methods.
• MassHealth, Taunton and Brockton office. CCBC is a Designated Certified Application Counselor Organization in Taunton, Attleboro, and Brockton on behalf of the Health Connector. • National Alliance Mental Illness. CCBC has a longstanding relationship with NAMI as a training resource and local partner.
• Transformation Center. CCBC has utilized the consultation services of the Transformation Center with respect to its development of the role of peer specialists in service delivery.
• Brockton Neighborhood Health Center • Cape Verdean Social Club in Brockton. The BH CP will expand the existing relationship and engage the members of the social club as natural community supports.
• Haitian Social Club in Brockton. The BH CP will expand that relationship and engage the members of the social club as natural community supports. • Good Samaritan Hospital. • Morton Hospital.
• Sturdy Memorial Hospital.
• Mainspring Homeless Shelter. The BH CP will initiate monthly meetings on EEs who are homeless and living at the shelter as a renewal to similar case review meetings conducted by the CCBC Community Support Program (CSP) programs in 2010-2015.
CCBC will also serve the demographic population that utilizes hospital emergency rooms at Sturdy Hospital in Attleboro, Brockton Hospital in Brockton, Good Samaritan Hospital in Brockton and Morton Hospital in Taunton. These hospitals have high number of persons with severe and persistent mental illnesses and substance use disorders who will benefit from BH CP intervention.
CCBC’s currently operating Community Support (CSP) and Program for Assertive Community Treatment (PACT) programs provide a strong presence in Brockton, and a solid reputation and foundation of expertise that will allow the BH CP to build customized models of care coordination, health and wellness activities, seamless transitions of care from hospital ED’s, and inpatient med-surgical units. The connections have also grown during CCBC’s implementation of the Emergency Service Program (ESP) program in Brockton, Taunton and Attleboro.
CCBC’s familiarity with the demographics has resulted from established a number of programs and community partnerships in Taunton, Attleboro and across Bristol County. These affiliations will ensure that all staff, including newly hired BH CP staff, are aware of community resources in the Taunton and Attleboro areas. In Brockton, the ESP will have nearly 12 months of experience by the time of the start of the BH CP program in providing much needed interventions to vulnerable populations many of whom will be identified as potential Enrollees for the BH CP. Combined with the CSP, CCBC will have a host of community resources that are updated through the work of CSP and ESP programs to ensure their effectiveness.
c. Overview of 5-Year Business Plan
Community Counseling of Bristol County (CCBC) is excited to implement the Behavioral Health Community Partner (BH CP). CCBC will serve Enrollees in the areas of Attleboro, 3 Brockton and Taunton in the Southeast Region. Our projected volume will be 942 by the end of Program Year 1 and 2,000 enrollees by the end of Program Year 2.
CCBC is well positioned to serve MassHealth members in these areas who present with Serious Mental Illness, Substance Use Disorders, have complex co-occurring medical conditions, and have been affected by or at risk of losing access to health care due to a host of social determinants.
Our agency has a long history of providing service to these communities since 1970: We are the largest provider of outpatient behavioral health services in these communities. We serve the DMH clients in our PACT and CBFS programs in Attleboro, Brockton and Taunton. CCBC is the Community Service Agency (CSA) serving children with Severe Emotional Disturbances and their families in the Taunton/Attleboro area. Our Community Support Program (CSP) works with primary care providers, hospital Emergency Departments and inpatient psychiatric units in these areas and across the Southeast. In its CSP service CCBC is able to engage 75% of the referrals we receive, a key competency for the Behavioral Health Community Partners.
These services are complemented by a wide range of other social services provided by CCBC, including Emergency Services, partial hospital and day treatment, HIV Services, specialty housing, Elder Mobile Outreach, and an active community presence on initiatives related to health and wellness, prevention of opioid overdoses, and suicide prevention.
The strength of our business plan is bolstered by our close working relationship with Steward Health Care in five ICB contracts that include care coordination activities that resemble much of what is required in this RFR and as a member of their Thought Leader work group providing additional input into their relationships with CPs.
Our five-year business plan under this model has begun since notification of the award. During our preparation period, we have designed and will shortly install the care management module and recruit key staff, including enough Care Coordinators to begin activities with 900 referrals on June 1, 2018, based on MassHealth’s commitment to provide this volume of referrals at the start of the program.
We view program years one and two as a time to implement the program fully, establish strong working relationships with the ACOs in these areas, primarily Steward, BMC-BACO, BMCSignature, and the Community Care Collaborative, while developing an alignment with these stakeholders and community providers to understand the population identified by MassHealth.
Year three will be a year to implement targeted population health interventions based on the strengthened alignment that includes population health analysis to address gaps in care among all of the stakeholders. In years four and five CCBC envisions consolidation of the program model and a transition to shared savings and shared risk with the ACOs and MCOs as the value of the BH CP is identified. Within this plan, we recognize the many challenges, including engaging persons who have not yet reached the stage of change where they will consistently accept services, or who only intermittently touch health and behavioral health services. We have built the culture of the agency to be responsive to referral sources, individual clients, and other providers to be of service when requested. CCBC will be ready to stand up as the BH CP on day 1 with a skilled, trained, and competent workforce backed by an agency with strong clinical capacity and a positive reputation in these communities.
Another challenge is the perception of behavioral health as a second-class health care diagnosis, along with the providers who deliver the services. CCBC has been addressing this obstacle through our strengthening partnership with Steward Health Care, our collaboration with Brockton Neighborhood Health Center as a supporter of our program in Brockton, and our continuing relationship with Greater New Bedford Community Health Center and Manet Community Health Center.
The longer-term challenge for this program is to align the stakeholders (MassHealth, MCOs, MBHP, ACOs, and providers) towards a common understanding of the population in terms of gaps in care and outcomes that can be achieved; a common perspective on how to drive care towards efficiencies in service delivery and improved management of the care; and alignment of payment methodologies to reward stakeholders less for volume and more for outcomes. This is a long-term goal. If common methods of profiling the population’s patterns of care, service utilization, and formula for Total Cost of Care are developed by Year 3, we will be prepared for assuming some type of risk with the ACO partners in graduated levels in years 4, 5 and beyond.
CCBC will address the workforce shortage in behavioral health care by drawing from our staff of CSP workers to become Care Coordinators. Based on the commitment from MassHealth to refer this volume to CCBC, we expect to add 1238 assigned members on July 1st, and 897 in October to reach our projected capacity by the close of BP-1 on December 31, 2018. Our DSRIP funding will allow for hiring, training and orienting these staff over the course of two months prior to implementation, allow for sufficient investment in our Care Management module, and related operational costs.
We recognize the challenges of recruiting up to 50 Care Coordinators that a fully implemented program will entail as well as the technological challenges of starting up a new Electronic Care Management module that can improve communication with the ACOs. However, we are gaining invaluable experience in our current project with Steward Health ACO Pilot, our CSP program, and our growing community presence in prevention, education, housing support and outreach activities in these communities.
These are some of the challenges and opportunities of “Incremental Care” as described by Atwul Gawande that will become more of a focus of health care delivery, especially for Medicaid populations and especially for persons who are affected by social determinants of health and also have the complex, co-occurring conditions described by MassHealth in this RFR. CCBC is well positioned to address these challenges and build strong partnerships with ACOs, MCOs and other providers to chart a path to improved outcomes and reduced total cost of care.