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Merrimack Valley CP

Executive Summary

CP Composition

The Merrimack Valley Community Partnership (MVCP) is comprised of Elder Services of the Merrimack Valley (ESMV) and our affiliated partner, Northeast Independent Living Center (NILP). In 2004, Elder Services of the Merrimack Valley (ESMV) and Northeast Independent Living Program, Inc. (NILP) established The Merrimack Valley Aging & Disability Resource Consortium (MV ADRC), the first of its kind in the state of Massachusetts.

ESMV is a private non-profit agency that provides services, programs, education, and assistance to older adults, adults with disabilities, families, and caregivers. NILP is a consumer/peer run Independent Living Center, providing advocacy and services to people with all disabilities in the greater Merrimack Valley and Northern Region who wish to live as independently as possible in the community. Together, we serve as a community resource for information and advocacy on issues related to aging and living with a disability. We have developed a team who work together to offer Options counseling and Care Transition services to adults and elders who are eligible and possibly receiving nursing home care but are seeking community based options. We have also jointly published the Green Book, an extensive resource guide published in English and Spanish. Over 20,000 Green Books are distributed free of charge each year.

The MV ADRC has combined the strength of two agencies; ESMV and NILP, to create the Merrimack Valley Community Partnership for LTSS (MVCP) for the Mass Health Delivery System Restructuring Initiative. Through our combined efforts, the MVCP will provide assessment, integrated long term support services, and disability expertise consultation to elders and peer support services to adults with physical, intellectual, recovery, and developmental disabilities, children, families, and caregivers. Services and programs support a person-centered approach and choice counseling to assist with long term care needs. The MVCP also provides care coordination, support during transitions of care, health and wellness coaching and linkages to social and community services. The long standing partnership established by NILP and ESMV to create the MVCP has fostered many collaborative partnerships within our community and a shared belief system in consumer choice and consumer self-determination which underlie person-centered care.

The MVCP will be supported by a Governing Body, a Consumer Advisory Board, and the Northeast Community Collaborative. (NCC) The NCC is a collaboration of community based organizations with experience and expertise supporting all or some of the following populations of individuals with complex LTSSS needs:

a) Individuals with complex LTSS and Behavioral Health (“BH”) needs.

b) Individuals with brain injury or cognitive impairments.

c) Individuals with physical disabilities.

d) Individuals with Intellectual Disabilities and Developmental Disabilities 2 (“I/DD”), including Autism.

e) Older adults (up to age 64 ) with LTSS needs

f) Children & youth (ages 3 – 21) with LTSS needs

Community Partners Population Served

The MVCP has contracted with EOHHS to provide LTSS services to individuals residing in the greater Lowell, Lawrence and Haverhill service areas. According to the most recent data, 13% of the LTSS CP Identified population resides in the Haverhill service area, 47% reside in the Lawrence service area, and 40% reside in the Lowell service area. 19% of the LTSS CP Identified population fall between the ages of 3-13, 8% between the ages of 14-20, 21% between the ages of 21-44, and 51% between the ages of 45-63. 24% of the identified population have been identified as needing 3 or more LTSS services. 41% of the identified population have been identified as having 1 or more emergency rooms visits, and 21% of the identified population have 3 or more medical conditions.

Overview of 5-Year Business Plan

Merrimack Valley Community Partnership (MVCP), working with the Northeast Community Collaborative (NCC) as a strategic network partner, affirms our commitment to EOHHS’ goals for the LTSS CP program over the next five years. Our strategic goals and strategies, which are closely aligned with EOHHS’s goals, are as follows:

EOHHS’ Goal MVCP’s Long Term Goals
Improve collaboration across ACOs, MCOs, providers and CBOs Expand community linkages with ACOs, providers and other community partners through our community-based coalition, NCC.
Improve Enrollee experience and quality of care; assist Enrollees in access to settings and levels of care Invest in initiatives to increase Enrollee awareness of available services and supports. In addition, we will support educational and training initiatives to improve access to culturally and linguistically appropriate services.
Leverage ACO and MCO expertise serving LTSS needs Collaborate with ACOs and MCOs to leverage infrastructure including connectivity. We will also educate ACOs and MCOs regarding LTSS CP services.

MVCP’s timeline calls for rapid implementation to create complex systems, including Information Technology (IT). Educating networks, ACOs, MCOs and others will be integral to the challenge of having others appreciate the value of LTSS. We will use DSRIP funds efficiently, leveraging resources available across the ACO system. Our goal is to participate in an integrated system, eliminating silos that have historically impeded care integration.

ESMV has been able to successfully sustain programs and initiatives such as its Community Care Transitions Program, initially funded by CMS, by leveraging its strong partnerships with local hospitals and contracts with SCOs and other health care providers to secure new payers for our services. We plan to utilize these and other approaches to develop a sustainable foundation for LTSS CP services.

Specifically, the MVCP will sustainably fund the proposed infrastructure and capacitybuilding investments and LTSS CP supports during the Contract Term and following the initial Contract Term through:

  • DSRIP Dollars (initial investment and ongoing funds distribution associated with volume) 
  • Shared savings initiatives developed over time with the ACOs/MCOs
  • The ability to sell services to MCOs for non-CP eligible individuals who can benefit from CP services to manage the Total Cost of Care (TCOC) for more Enrollees
  • Managing fixed costs associated with IT, licensing, fees and general expenditures over time
  • Identifying and developing new services for ACO, MCO and commercially enrolled individuals that support consumers remaining independent in the community and decrease TCOC associated with avoidable hospital utilization
  • The ability to expand our contracted service area to accommodate members identified as needing LTSS services

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