offered by

Riverside Community Care, Inc.

Executive Summary

a. CP Composition

i. A high level description of the Affiliated Partners that comprise the CP.

Riverside Community Partners is the name for our Behavioral Health Community Partners program (BH CP): Riverside Community Care, Inc. is the contractor with EOHHS and is responsible for managing this service and ensuring compliance with all contract requirements. Our BH CP includes six Affiliated Partners: Brookline Community Mental Health Center, Inc., The Edinburg Center, Inc., North Suffolk Mental Health Association, Inc., The Dimock Center, Inc., Lynn Community Health Center, Inc. and the Uphams Corner Health Center, Inc. Riverside and each Affiliated Partner will have teams of care management/care coordination staff situated across our service areas to provide the BH CP services.

Riverside and our Affiliated Partners are long-time providers of behavioral healthcare in our respective communities. Three of our Affiliated Partners, The Dimock Center, Lynn Community Health Center, and Uphams Corner Health Center are also health centers that provide behavioral healthcare as an important component of their overall health services. Riverside, the Edinburg Center and North Suffolk Mental Health Association all have multiple contracts with the Department of Mental Health, Department of Public Health and other state agencies and provide a broad range of programs such as CBFS (soon to become ACCS), emergency services, and more. Additionally, all the organizations in Riverside Community Partners are contracted MassHealth outpatient providers and have served MassHealth recipients for many decades. Each organization is well known as an important resource in the communities it serves and is familiar with local resources, institutions, government entities and health care providers. All have had prior experience in coordinating care for people served and view the BH CP as an opportunity to provide further value by furthering integration between medical and behavioral healthcare as well as other social services and supports.

b. Community Partners Population Served

i. List the Service Areas covered by the CP

Riverside Community Partners intends to cover the following Service Areas:

• Greater Boston Region: Boston- Primary, Revere,, Somerville, Quincy

• Northern Region: Lowell, Lynn, Malden, Woburn

• Central Region: Framingham, Southbridge, Waltham

ii. Describe the demographics of the populations the CP supports or intends to support in the Service Areas covered

The Service Areas covered range from north of Boston, through Boston itself and south and west into far central Massachusetts. With such a large area, the populations Riverside and its Affiliated Partners currently serve and expect to serve as a BH CP are diverse in all aspects: ethnically, LGBTQ identity, primary language, urban vs rural lifestyles, etc. Each organization that is part of Riverside Community Partners is experienced in serving these diverse populations because of our collective decades of experience in these communities, and each of us have diverse staff to help us deliver culturally competent care. The populations we expect to serve as a BH CP will include adults with serious mental health and/or addictions challenges, some with co-occurring medical issues. These are the people Riverside and each Affiliated Partner have been serving for years.

One of the benefits of our BH CP is that when there are special needs presented by the diverse population who may be referred to us, each Affiliated Partner has the option of seeking assistance from the other organizations to better meet an individual’s unique needs. For example, some of the communities have a larger Asian population than others; North Suffolk serves a diverse population that includes Cambodian/Khmer, Chinese, Vietnamese families. Uphams Corner serves a particularly diverse and underserved population in Boston. Both Lynn Community Health Center and Riverside have significant expertise in serving individuals with behavioral health needs who have experienced significant trauma. In short, these examples illustrate that we are well prepared to serve the diverse populations likely to be referred to us for BH CP.

c. Overview of 5-Year Business Plan

Riverside is confident that over the course of the initial 5 years of BH CP operations, we will achieve the goals, outlined below, that will prepare us for ongoing sustainability. The DSRIP investments will enable us to address the start-up costs that are inevitable during early years of operation while caseloads are building, equipment and systems are being established and refined and staff are gaining experience in this service model. The following is a brief description of our long-term goals and anticipated challenges:

  • Technology and Information: Our goal is to establish the ability to operate the program in a fully efficient, electronic environment in which all records and documentation are written, stored, and communicated electronically. To this end we have contracted for care management software, Care Navigator that is currently being refined to meet the specific requirements of the Massachusetts BH CP program and Riverside’s unique specifications. We expect that over the initial contract period each of our Affiliated Partners will utilize Care Navigator or their own electronic care management software (Identifi Care used by our Affiliated Partners that are also members of C3) that will meet all contract requirements and be able to feed directly into Riverside’s Care Navigator system. Furthermore, we have a goal of establishing robust electronic bi-directional communication access with each of the ACOs with which we will be working (and where possible directly with physician practices) using either our Care Navigator portal or a newly developed product supported by SAMHSA that Riverside is piloting with several ACOs. We recognize that establishing seamless electronic communications between different software systems has been a challenge for all providers nationally and expect that we will encounter challenges in meeting this goal as well. However, given the SAMHSA “translator” we are hopefully we may succeed rapidly and even be able to help other BH CPs adopt similar capabilities.
  • Workforce Development: Our goal is to have all care coordination teams across Riverside Community Partners fully staffed with well- trained employees who find the work satisfying and make a long term commitment to this work. We recognize that there is currently a workforce crisis in health and human services and have sought to budget salaries that will help us be competitive in hiring and retaining staff. We have also set a goal of seeking to hire staff who have lived experience in the behavioral healthcare system and can use their peer status to the benefit of Enrollees and/or who have dual language capacity and understanding of the culturally diverse populations we are likely to serve. We will be reviewing the State-wide investment opportunities (i.e. tuition reimbursement) that are expected to soon become available to help us in this goal, where possible. Meanwhile, we have developed a robust plan for hiring and training initial and later-hired staff and expect to continually refine our efforts as we gain experience.
  • Program Administration: Our goal is to develop a strong administrative function to manage the BH CP program and build strong, collaborative relationships with MassHealth and the ACOs/MCOs with which we will work. To this end we have established a central administration team at Riverside to oversee the BH CP contract, support all our Affiliated Partners, and ensure contract compliance and quality care. We have hired a BH CP Director and have dedicated time 3 from Riverside’s senior management team to this program (i.e. our Vice President for Quality Management and Assistant Vice President for Behavioral Health Services). The BH CP Director is responsible for overseeing BH CP operations, including receiving referrals and reporting as required to EOHHS, among other tasks. We will be utilizing Riverside’s Administration and Finance Department to manage billing and other fiscal operations. We also intend to establish the requisite Governance and Quality Management Committees to ensure strong oversight and collaboration across all Affiliated Partners.

Sustainability: We are confident that our BH CP program will demonstrate value in improving health outcomes and reducing healthcare costs during the initial 5 year period so that ACOs will choose to invest in Riverside Community Partners for long-range sustainable operations. The goal of improving collaboration between healthcare and behavioral healthcare and the cost savings likely to be realized from a more coordinated system of care will provide the foundation for discussions with ACOs/MCOs about future investments. Additionally, we are interested in discussing alternative payment models in support of these goals. Prior to the completion of the initial 5 year contract, we intend to collaborate with ACOs/MCOs to develop a new contract for the continuation of their partnership with Riverside Community Partners.

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