CP COMPOSITION
The Lowell Community Health Center (Lowell CHC) and two Affiliated Partners known as Lowell House, Inc. (LHI) and The Mental Health Association of Greater Lowell, Inc. (MHA)- collectively know as “The Greater Lowell BH CP- represent three best practice Behavioral Health (BH) organizations in serving the Greater Lowell area.
The Greater Lowell BH CP partners bring over 300 years of experience in total providing evidence-based BH to residents in Northern Massachusetts. We provide data-driven BH care coordination, care management, and BH services and supports to more than 7,600 individuals with disabilities and mental health challenges annually, helping some of the most underserved consumers in the State live as independently as possible in the community, while achieving their wellness and recovery goals. We serve individuals with Serious Mental Illness (SMI) and Substance Use Disorders (SUD) as well as Long Term Services and Supports (LTSS) needs Our three organizations offer seamless access points that support access and care integration for Lowell residents. We help members of our community live as independently as possible while helping them achieve wellness and recovery goals. The Greater Lowell BH CP seeks to improve member satisfaction, quality, and cost-effectiveness and are highly innovative in our approach to BH care delivery for underserved individuals.
The Lowell CHC was founded in 1970 by Lowell General Hospital to provide public housing nursing services. Lowell CHC was incorporated in 1985 as a separate 501(c)(3) Federally Qualified Health Center (FQHC) for low-income patients. In 2000, Lowell CHC opened the Metta Health Center, designed to meet the unique needs of Lowell’s Southeast Asian community. By 2009, Lowell CHC established six separate locations. The Lowell CHC contracts with MassHealth as well as the Bureau of Substance Abuse Services (BSAS).
LHI has provided quality, accessible addictions services and supports to the Greater Lowell community since 1971. We offer a range of inpatient and outpatient treatment and living options as well as care management services for individuals with medically complex needs (e.g., co-morbid HIV/AIDS and SUD). LHI specializes in reaching and treating individuals with SUD including those dually diagnosed and who are homeless and/or recently incarcerated. Today, LHI is in the process of co-locating with Lowell CHC at their main location, offering the ability to deliver fully-integrated BH and SUD services.
MHA was founded in 1953 to serve the needs of the Greater Lowell community. Its mission since its founding has been to promote mental health, prevent mental illness, and provide quality care and treatment for people with mental illness and developmental disabilities. MHA is an ideal partner for Lowell CHC and LHI, given its ability to deliver a variety of services required to participate as a BH CP.
COMMUNITY PARTNERS POPULATION SERVED
Greater Lowell BH CP proposes to serve MassHealth Enrollees in the Greater Lowell area. Lowell CHC, LHI, and MHA are crucial organizations within the community, which is bound 2 geographically by the Merrimack and Concord Rivers and surrounding elevations which, together create a naturally occurring community where local health care delivery is essential.
The Lowell CHC, LHI, and MHA offer extensive and complementary experience in delivering quality care, including CBFS and CBHI services to consumers with SMI and SUD. Seventy-four percent of the Lowell CHC population has MassHealth coverage. Similarly, MHA’s population is approximately 71% MassHealth funded, and another 22% of the population is dually eligible. CBFS consumers are 100% DMH funded. LHI’s patient population is 83% Mass Health, 5% BSAS.
Approximately 58% of the Lowell CHC’s BH population also has a co-occurring SUD diagnosis. The Health Center primarily provides Medication Assisted Treatment (MAT) to consumers who receive the full continuum of integrated primary specialty, BH, and SUD services, where clinically appropriate. We serve predominantly low-income, immigrant, and refugee populations. Our patients with high BH needs (SMI, SED, and SUD) often present with a variety of different diagnoses including PTSD; Anxiety; Depression; and pediatric diagnoses such as Separation Anxiety. Half of our patients need interpreter services, with Spanish, Portuguese, and Khmer the highest need languages: top language needs for patients seen at the Metta Health Center include Khmer and Swahili, along with numerous dialects for patients from Nepal, Burma, Bhutan, Congo, and other nations.
LHI provides services to individuals with a SUD diagnosis, including individuals who are dually diagnosed with MH and SUD conditions. LHI’s Outpatient Clinic is licensed by Department of Public Health as both a substance abuse and mental health clinic where licensed clinicians specialize in treating individuals who are dually diagnosed. Current groups offered include a Men in Recovery group and a Women in Recovery group that meet weekly, as well as an Early Recovery group that meets twice per week. A cornerstone of our services includes care management and care coordination services for the individuals we see at LHI. LHI recognizes the need to coordinate care and services for individuals who are dually diagnosed. LHI works closely with many partners in the community to best serve the individuals in their care. Currently, LHI is working with Center for Hope and Healing to provide a therapeutic group for individuals diagnosed with SUD who have experienced trauma. If patients require BH services beyond those offered by LHI, we make every effort to refer and coordinate those services as we continue to provide SUD treatment.
Many of MHA’s patients with SMI also have co-occurring conditions. A description of services for individuals with SMI appears above. For individuals with co-occurring conditions, MHA refers patients for services to the Lowell CHC, LHI and other organizations. Under the BH CP program, The Greater Lowell BH CP will make every effort to support patients within the BH CP, offering services for individuals who are treated for SMI and have SUD needs to receive integrated care.
Lowell CHC has been providing services to individuals with an SMI for over 46 years and offers a full array of services to the SMI population. The Lowell CHC provides services in all four of EOHHS’s required categories to deliver BH CP services. Most notably, the Lowell CHC delivers fully integrated co-located services to nearly 300 individuals who are seen at the Health Center for primary, specialty, BH and SUD care as needed. Lowell CHC locations offer access to the full continuum of care for some of the most vulnerable individuals in Massachusetts. Also, SUD LHI provides services to approximately 2100 individuals annually, 3 and of those, 75% have a secondary mental health diagnosis. To better serve individuals who have co-occurring SUD and mental health disorders, LHI became licensed as a mental health clinic in 2015. Additionally, LHI is a Children’s Behavioral Health Initiative (CBHI) hub providing therapeutic services as well as care coordination for adolescents seen at our site; this includes participation in a treatment team and care planning meetings, which occur both telephonically and in-person. An LHI outpatient clinician administers the CANS (Child and Adolescent Needs and Strengths) assessment to individuals aged 21 and under to evaluate the need for services such as therapeutic mentoring, family support and training, and/or in-home behavioral services. As needed, the clinician makes referrals for these specific services.
Affiliated Partner: MHA. Of the 1400 individuals we serve in MHA’s outpatient clinic, approximately 200 individuals meet BH CP eligibility criteria due to MassHealth participation and an SMI diagnosis. For individuals with SMI, MHA offers CBFS services. Individuals served are assigned to small teams headed by Team Leaders who oversee several direct care staff. Through this program, MHA offers person-centered care that incorporates outreach, assessment, care planning, treatment planning and care management and coordination which closely resembles the services required to participate as a BH CP. For CBFS clients, MHA’s outcomes are routinely superior to both the Area and Statewide averages for several key indicators, providing ideal preparation to serve as a BH CP in collaboration with The Greater Lowell BH CP.
Among many services for individuals with SMI, MHA also offers: Therapy offered at our clinic and on-site at Lowell area schools, services for adults involved with the criminal justice system, and in client’s homes when appropriate; medication management, and services for children and families impacted by an opiate overdose.
In 2016 Lowell CHC touched the lives of 50,000 people—almost half the population of Lowell. Lowell CHC’s target populations present with multiple and complex health care needs that are further complicated by their involved medical histories, cultural and linguistic barriers, lack of consistent medical care, and socioeconomic status. 83% of our patients live at or below 200% of the Federal Poverty Level, and 39% are best served in a language other than English. In 2016, 68% of patients identified as Non-Hispanic/Latino, with 32% Hispanic/Latino. Racially, 45% of patients identified as White; 26% Asian (mostly Cambodian); 14% Black/African Immigrants, and 15% Multiracial/Unreported. Lowell CHC is accredited by the Joint Commission for health care delivery, and is among the top five community health centers recognized nationwide by the Office of Minority Health for the delivery of culturally competent care.
OVERVIEW OF 5-YEAR BUSINESS PLAN
Goals and Challenges
The Lowell CP goals align closely with the State’s goals to:
Support individuals with high BH (and LTSS) needs to help them navigate the complex BH system providing coordinated support services
Improve the Enrollee experience by holistically engaging individuals with high BH needs with services that strengthen, enhance and diversify access for individuals and families we serve
Assist individuals in integrating into the community through attaining valued community roles, active membership in local organizations and meaningful relationships
Incorporate an enhanced data-driven decision-making process to guide clinical and administrative decisions to improve capabilities that enhance care delivery
Support community first values, SAMHSA recovery principles, and culturally competent care delivery by adopting evidenced- based, best practices
Collaborate with ACOs, MCOs, CPs, and community organizations to integrate care and address the social determinants of health Challenges and solutions associated with meeting the State’s BH CP Contract requirements:
| Challenges | Solutions |
|---|---|
| Support true care integration | Utilize a single system that supports a full continuum of behavioral health care service and data integration among Affiliated Partners, ACOs, and others; Educate Enrollees and providers regarding integration |
| Connect Enrollees to Community-based Organizations (CBOs) to address social determinants of health | Leverage our close relationships with local organizations that serve BH CP Enrollees |
| Collaborate with multiple ACO Partners, each with different IT systems and processes | Work with ACO partners to create assessments and care plans and, to create a “bridge” between the ACO data system and the BH CP data system |