This page, Eliot Community Human Services, Inc., is offered by

Eliot Community Human Services, Inc.

Executive Summary

Eliot has chosen to become a sole entity Community Partner for eleven catchment areas north and west of Boston. Because Eliot currently provides a range of behavioral health services in all of these areas, the organization is exceptionally well positioned to pioneer the BH CP initiative as of July 1st. The Implementation and Administrative Team that will drive the start up of this new care coordination model has been convened and is preparing for the launch by:

● Finalizing ACO/MCO and community affiliations;

● Honing technological systems to ensure flawless data collection, exchange and analysis;

● Recruiting, hiring and training the requisite staff; and

● Phasing in care model components.

Eliot is fully prepared to transform health care delivery by partnering with primary care, medical, community and behavioral health services to deliver a comprehensive, coordinated and integrated system of care for our enrollees.

a. CP Composition

i. Eliot has chosen to be a free standing Community Partner. The extensive and multifaceted continuum of behavioral health services provided by Eliot supported by a comprehensive, state-of-the-art infrastructure give the organization the depth and breadth to deliver an integrated system of care for adults with Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD). Known for exceptional case management and care coordination across its service network, Eliot has the capacity to deliver an integrated care system relying on both internal and external resources and services. As the sole entity coordinating the design, delivery and integration of services for our enrollees, Eliot can promote and ensure a more efficient, high quality and focused collaboration with primary care, medical, community and behavioral health providers.

The clarity provided by a sole entity serving as the Community Partner establishes a single point of accountability and contact for partners, enrollees, providers and community linkages. This protects against confusion and duplication. The onus is on Eliot to transform the behavioral health care system within the Service Area to one that is an integrated whole system of care for each enrollee, coordinating medical, community and behavioral health services.

b. Community Partners Population Serve

i. Service Areas

Region  Service Area
Greater Boston Somerville
Greater Boston Revere
Northern Beverly
Northern Gloucester
Northern Lowell
Northern Lynn
Northern Malden
Northern Salem
Northern Woburn
Central Framingham
Central Waltham

ii. Demographics of the populations served The people Eliot intends to support in the above Service Areas will come with complex and high risks relative to their behavioral health. The identified population experiences extensive and often long term challenges that impact their physical and mental health, family life, employment and living situations. Our intended population may have difficulty with transportation, inadequate housing, financial concerns and/or family turmoil, all of which create barriers to engagement in treatment. Most have been involved with multiple providers over many years, frequently discontinuing or relapsing for a variety of reasons. Often ongoing involvement with the “system” creates a distrust and even an aversion to services and providers. Recognizing this, Eliot understands that engagement is the most critical aspect of ensuring positive outcomes. Understanding and addressing the barriers and challenges that each experiences is paramount to successful engagement and establishing a partnership with our enrollees. The Community Partner must first be a partner with the enrollee, assessing all the needs and attending to the whole person.

Eliot’s experience with people in the above Service Areas reveals the following information:

● 60% have comorbid medical conditions;

● Nearly 70% have co-occurring substance use and mental health disorders;

● A population impacted by poverty and trauma; and

● Approximately one quarter are receiving some level of LTSS services.

As stated, Eliot understands the complex risks and high needs of the people to be referred for Community Partner services. We have worked closely with many of these men and women for years and have learned from them how best to meet their complex needs.

C. Overview of 5-Year Business Plan

Year 1: Implementation

Goal: to finalize and implement CP model that addresses the complex and multifaceted needs of the identified enrollees in a comprehensive and effective way


● Care Model implementation

● Implementation of Care Management Platform and information sharing systems

● Staffing (recruitment, hiring, training, retaining)

● Member engagement (identifying, outreach strategies, supporting)

● Partnering and integrating(ACOs, MCOs, State Agencies, community linkages)

● Data collection, sharing and analysis

Year 2: Analysis and refinement

Goal: to review the data, outcomes and other information from year one to determine efficacy of the model and the work; and to use the information to adjust, refine and improve as indicated


● Implement marketing strategy to improve awareness of the CP services within the member population and within the service provider community

● Utilize data to enhance engagement strategies and efficacy

● Implement advanced integration between Care Management Platform and ACO/MCO partners

● Identify integration issues with PCP partners and develop strategy to address any barriers

● Identify technology gaps and develop strategies and technologies to improve processes

● Utilize enrollee feedback and experience to improve quality of care

● Utilize change management strategies to identify barriers and best practices to deploy targeted clinical practices and interventions.

Year 3:  Analysis, refinement and innovation

Goal: to review the data, outcomes and other information to determine efficacy of the work and to use the information to adjust, refine and improve as indicated; AND introduce enhancements such as technology, telemedicine, best practice treatment options, expand community collaborations


● Assess marketing strategies and activities and develop improved techniques to create increased awareness of the CP services

● Begin full implementation of technological strategies to continue to improve information sharing

● Implement strategy to improve real time systematic response to enrollee’s needs and changes in their care 

● Analysis of enrollee outcomes and refinement of CP interventions to target and support enrollee’s in improving their behavioral health and medical needs

● Implement telemedicine and other innovative treatment technologies wo support enrollees needing remote and mobile treatment solutions

● Assessment of current workforce including training and recruitment and retention strategies to determine effectiveness and strategy to make continuous improvement

Year 4:  Analysis, refinement, innovation and sustainability

Goal: to review the data, outcomes and other information to determine efficacy of the work and to use the information to adjust, refine and improve as indicated; AND introduce enhancements such as technology, best practice treatment options.

● Analysis of data related to population health, target outcomes, and predictive analysis on reducing negative health consequences of our CP population

● Identify variables contributing to successful health outcomes and barriers within service system limiting CP and ACO interventions in improved

● Develop and deploy innovative technological and communication techniques to engage enrollees with the highest TME and struggles with improving upon health outcomes

● Identify barriers within the care delivery system and strategies with ACO/MCO to reduce and eliminate barriers

● Implement strategy to enhance workforce, increase recruitment and retention of staff at all levels

Year 5: Analysis, refinement, innovation, sustainability and enhancement

Goal: to review the data, outcomes and other information to determine efficacy of the work and to use the information to adjust, refine and improve as indicated; AND implement final strategies for sustainability

● Full review and assessment with ACO and MCO partners to determine gaps in care system

● Develop strategy to address all gaps within care system and collaborate with ACO and MCO partners in a stepwise manner to ensure we have optimized information sharing, real time response to enrollee needs, and focused on improvement of CP population health

● Assessment of Eliot CP workforce to determine training, recruitment and retention needs with a focus on workforce sustainability

● Collaborate with all partners and CP workforce to ensure strategies and plans for sustainability are realistic and implementation

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