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Open Sky dba Central Community Health Partnership

Executive Summary

CP Composition

Alternatives Unlimited, Inc. (Alternatives), as the Lead Agency with its Affiliated Partners and Material Sub Contractors, including, but not limited to, The Bridge of Central Massachusetts, Inc. (The Bridge), LUK Crisis Center, Inc. (LUK) and Venture Community Partners (Venture) as Affiliated Partners and Center for Living and Working and Elder Services as a Material Subcontractors (CCHP), represents an ideal collective of premier human service organizations in Central Massachusetts which employ evidence-based practices to deliver both Behavioral Health (BH) and Long-Term Services and Supports (LTSS). We serve individuals with MassHealth coverage as well as other State EOHHS funded consumers. CCHP partners provide trauma-informed, best practice services to individuals with Serious Mental Illness (SMI) and Substance Use Disorders (SUD) who present with a variety of medical, physical and developmental disabilities.

Our unique application to EOHHS provides fully integrated BH and LTSS CP services to those individuals who require them. Our organizations are deeply connected with providers, Accountable Care Organization (ACOs) and other community-based organizations (CBOs) within our service area. Given the depth and breadth of existing provider relationships, we are working with ACOs about developing unified assessments and treatment plans to play a meaningful role in integrating care.

Goals. CCHP’s goals align closely with the State’s goals to:

•     Support Enrollees with high LTSS needs to help them navigate the delivery system

•     Improve the Enrollee experience by holistically engaging Enrollees with high LTSS 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, evidence-based decision-making process currently used in our organizations today to guide clinical and administrative decisions

•     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

Community Partners Population Served

Anticipated Number of Enrollees

CCHP/LTSS will have the capacity to serve approximately 1,000 LTSS CP Eligible individuals, within the proposed Service Region, during the first year of service delivery. We will develop the ability to serve1,700 or more individuals over the course of the contract.

Service Areas

CCHP serves MassHealth Enrollees in the Athol, Framingham, Gardner-Fitchburg, Southbridge, Worcester service areas.


While the Greater Worcester region has several strong health care services, vulnerable populations – such as the elderly, low-income residents, non-English speaking residents, and those with disabilities – experience difficulties in accessing primary care and oral health services, despite expanded health insurance coverage in the state. Challenges include long waiting lists to schedule appointments, long wait times, limited transportation to and from health care, linguistic and cultural barriers, complexity of navigating the health care system, and a lack of sensitivity among health care staff and administrative staff.

Overview of 5-Year Business Plan

CCHP has identified the following goals, anticipated challenges and plans for sustainability

Activity Budget Period
Develop and implement LTSS CP program in accordance with EOHHS requirements, Complete agreements and documented process with all ACO/MCO’s for our service area. Launch CCHP in July 1, 2018. Prep Budget Period
Fulfill CCHP’s enrollment targets and to meet EOHHS and ACO referral needs Build effective and collaborative integrated care partnerships with ACO partners, and other community providers Budget Period 1
Continue CCHP enrollment growth, Evaluate service delivery with ACO partners and Enrollees for performance improvement opportunities. Budget Period 2
Continue CP enrollment growth, service delivery improvement and begin to move towards sustainability as infrastructure supports begin to sunset Budget Period 3
Sustain enrollment targets, service delivery improvement and continue progress on sustainability Budget Period 4
Demonstrate sustainability and begin post EOHHS CP program negotiations with ACO’s for future CP services. Budget Period 5

Challenges and Solutions. 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 data integration among Affiliated Partners, ACOs and others Educate Enrollees and providers re: integration Leverage existing relationships
Connect Enrollees to social service agencies and community organizations to address social determinants of health Leverage the close relationships we have developed with local organizations throughout the community that serve Enrollees

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