offered by

Innovative Care Partners, LLC – LTSS CP

Executive Summary

a. ICP Composition

Innovative Care Partners, LLC (ICP) is a Consortium comprised of three Consortium Entities: Center for Human Development, Inc. (CHD), ServiceNet, Inc., and Gandara Mental Health Center, Inc. These organizations represent more than 150 years of combined history and experience serving the LTSS CP target population. The Consortium’s mission is to have a significant impact on the health and well-being of the residents of western Massachusetts by providing innovative, evidence-based care coordination and care management practices and programs. The organizations’ goal is to apply its state-of-the-art care coordination, information technology, and human expertise to improve the care experience and health outcomes of individuals enrolled in the MassHealth Behavioral Health Community Partners initiative. Achieving these goals is expected to result in reduced health care costs for this population. The ICP Governing Board named CHD to serve as Consortium Manager and provide centralized administrative functions and care coordination services, pursuant to the CP Contract, on behalf of the Consortium Entities. There are no Affiliated Partners.

b. Community Partners Population Served

i. Service Areas Covered: ICP serves the seven (7) service areas comprising the Western Massachusetts Region. They are Adams, Greenfield, Holyoke, Northampton, Pittsfield, Springfield, and Westfield.

ii. CP Population Demographics: The LTSS CP serves MassHealth enrollees who meet the program eligibility criteria as delineated by the EOHHS and who are referred by participating ACOs or MCOs. The Western Region is a predominantly rural area, surrounding the urban center of Springfield and smaller cities and towns. The target population is racially and ethnically diverse in the Springfield and Holyoke areas, including a significant number of non- or limited English-speaking enrollees.

c. Overview of 5-Year Business Plan:

ICP’s) business plan for the five (5) year period of the LTSS CP contract reflects the following goals:

a. Supporting Enrollees with complex LTSS needs and their families to help navigate the complex LTSS system in Massachusetts;

b. Improving the care experience, continuity and quality of care for Enrollees by holistically engaging Enrollees in care coordination and care management activities;

c. Facilitating collaboration between ACOs and MCOs and community-based organizations to break down silos and promote integrated care so that the social determinants of health are more effectively addressed for members with high LTSS needs;

d. Working collaboratively with ACOs and MCOs to avoid duplication of care coordination and care management services for the population with high LTSS needs; and

e. Promoting and supporting the values of Person-Centeredness, Independent Living, aging in place, and cultural competence.

ICP’s business plan incorporates strategies that address anticipated challenges, including, as examples, the following:

Potential Challenge Solutions/Strategies
Enrollee Resistance to LTSS CP services 1. Effective matching of Enrollees to Care Coordinators in terms of language, cultural affinity, and experience with presenting Enrollee conditions; 2. Enrollment Specialists and Care Coordinators trained in Motivational Interviewing (MI); and 3. Collaboration with Enrollee’s PCP, family members, and other care givers.
Personnel Recruitment and Retention 1. Comprehensive staff recruitment plan including job fairs, creative use of social media, electronic job boards and web-based outlets, professional search firms, and other outreach avenues ; and 2. Apply “Employer of Choice” strategies that have helped earn CHD “Best Non-profit Workplace” awards for the past two years.
ACO and MCO Engagement 1. Leverage and build on long-standing, existing positive relationships between Consortium Entities and participating ACOs and MCOs; and 2. Follow established Documented Processes with ACOs and MCOs, monitored in regularly scheduled Joint Operating Committee meetings and other means that have already begun during the Preparation Period.
Risk Sharing 1. Establish effective data analysis and reporting systems to allow timely monitoring of quality and financial measures; and 2. Maintain adequate cash and liquidity ratios.
Technology 1. Devote substantial, ongoing resources on effective information systems that meet contract requirements; 2. Maintain active involvement with State and local planning groups working toward interoperability among CPs, ACOs, and MCOs and connection to Mass HIWay; and 3. Continuously improve the CC/CM platform during the Preparation Period and beyond, including interfacing with ACO event notification systems to alert staff of inpatient and emergency department admissions and discharges and predictive data analytics to facilitate focused interventions to benefit Enrollees. 4. The eHana Care Management Platform has the capability of interfacing with event notifications system that will be utilized/selected by the ACOs.

Sustainability: ICP recognizes the need to develop revenue sources that can support future infrastructure investments beyond the DSRIP funding period. The ICP Consortium Entities are well established organizations that possess the financial and administrative resources necessary to sustain the LTSS CP program. They have demonstrated the ability to sustain numerous successful program initiatives when initial grant funding has ceased.

ICP will lay the foundation for generating future support by:

1. Establishing effective, collaborative relationships with ACOs and MCOs and building on those relationships throughout the 5-year program period;

2. Demonstrating the value of the CP initiative, in terms of positive health outcomes for Engaged Enrollees, by producing credible data that assesses each quality measure;

3. Collaborating with EOHHS, ACOs and MCOs to demonstrate the financial impact of CP supports in terms of reducing avoidable Medicaid costs;

4. Working with ACOs to develop a realistic model for ACOs to participate in CP funding through alternative payment approaches based on shared risk and shared savings methodologies; and

5. Building sufficient cash reserves to fund ongoing capital improvements and make infrastructure investments.

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