A. Community Partner Composition
The South Shore Community Partnership (SSCP) is a partnership between South Shore Mental Health (SSMH) and Spectrum Healthcare Systems which represents over 140 combined years of in-depth knowledge and expertise serving people with substance use disorders and mental health conditions. For the contract with the Executive Office of Health and Human Services (EOHHS), SSMH serves as the lead and Spectrum Health Systems is the Affiliated Partner. SSCP provides high quality care coordination for adults with complex mental, physical, and social needs. Our model of care includes a team of licensed mental health clinicians, Registered Nurses, and Care Coordinators who will develop and implement comprehensive, individualized care plans that integrate care across behavioral and physical healthcare, social services, and community supports.
SSMH is a private, non-profit, community-based service provider serving Metro Boston, the South Shore, and Southeastern Massachusetts since 1926. SSMH provides education, treatment and recovery services to 16,000 clients annually. Our comprehensive and integrated system of care provides services and supports necessary to meet the needs of individuals suffering from mental health and developmental issues, including severe and persistent mental illness (SPMI). Services include evaluation and counseling, medication services, case management, outreach, 24-hour emergency services, stabilization beds, early intervention, specialized intensive day and evening programs, supported employment for young adults, and residential opportunities. SSMH assists individuals in reaching their full potential through innovative, evidence-based, and culturally competent services.
Spectrum Health Systems is a private, nonprofit providing a continuum of addiction treatment services throughout Massachusetts including inpatient detoxification, residential rehabilitation, medication-assisted treatment, outpatient counseling, and peer recovery support. Founded in 1969, Spectrum has evolved from a single site program to a multilevel system of care, delivering specialized services for high-risk populations, including substance using women, young adults, criminal offenders, and individuals with cooccurring disorders.
Together, SSMH and Spectrum have joined forces to provide integrated care and comprehensive care coordination for individuals who need medical and behavioral health supports. We have extensive experience in care management and wraparound supports and have highly developed clinical pathways to get individuals into services quickly.
B. Community Partners Population Served
This partnership will serve individuals with mental illness, substance use disorders, and co-occurring disorders in the Quincy Service Area within the Boston Region. Both SSMH and Spectrum Health Systems have extensive experience working with individuals with complex behavioral health and social needs. The population served in SSCP mirrors the general population in the Quincy area; specifically, the majority are White/Caucasian (over 70%) with 10% Asian and 10% African American. Not surprising, the predominant language spoken is English followed by Spanish, Cantonese, Mandarin, Creole/French, and Vietnamese. Regardless of ethnicity or language spoken, the SSCP serves people with complex physical, mental, and social needs.
C. Overview of Five-Year Business Plan
SSCP is led by a Governing Body comprised of senior leadership in SSMH and Spectrum Health Systems which oversees the five-year business plan. The five-year business plan includes strategies to build financial viability beyond the contract period while creating a system of integrated care that produces quality care and better health outcomes for 2 individuals with complex behavioral, medical, and social service needs. In order to accomplish this, we need the technology and information sharing capacity, a highly trained workforce, and systems that are accountable for measureable and meaningful quality outcomes for individuals with complex, high service needs. Over the course of the fiveyear contract, SSCP will be guided by long-term goals for technology and information sharing, workforce development, and program administration.
Technology and information sharing:
The long-term goal of SSCP’s technology and information sharing strategy is to build the capacity to safely and securely share information across the healthcare system in order to coordinate care in real time between and among all providers. For this purpose, SSCP has purchased a care management software platform that provides secure communication between ACOs, MCOs, PCPs, SSCP, and Enrollees’ care team members, called Care Navigator©. SSCP is also using DSRIP investments to hire Information Technology (IT) staff to oversee development and implementation of the platform, provide ongoing monitoring and updating of the platform, and train and support staff over the five years of the contract.
Project goals for the following years include:
BP 1: Implement the Care Navigator platform so that it is operational across SSCP and includes Enrollee records and all reporting functions as required by EOHHS and ACOs.
BP 2: Incorporate the PreManage® event notification system into platform
BP 3: Monitor and make improvements in platform to ensure its interoperability with providers
BP 4: Create efficiencies in exchange of information between CP, ACOs, PCPs, and other providers
BP 5: Continue system adaptation to improve communication, information sharing, and integration of services
The long-term goal of SSCP’s workforce development is to form and foster a workforce trained in integrated care that will support individuals with complex behavioral, medical, and social needs and their families, help them navigate the complex system of BH and LTSS care, and engage with them to improve their experience and more importantly, their health outcomes. In order to accomplish these goals, SSCP has developed a workforce development strategy between SSMH and Spectrum Health Systems that includes a development of a robust, standardized curriculum, a comprehensive, five-year training plan, a targeted recruitment strategy, and career pathways for front-line staff.
Project goals for the following years include:
BP1: Recruit, hire, and train SSCP staff using the standardized, comprehensive curriculum developed during pre-budget period
BP 2: Increase cultural and linguistic capacity of SSCP through targeted recruitment
BP 3: Build career pathways for front-line staff through promotions and career development
BP 4: Revise and update training modules based on data from program operations, treatment plans, and the needs of population served
BP 5: Replicate training and staffing models throughout respective agencies to continue to build internal capacity for ongoing case management and care coordination
The long-term goal of program administration is to operate a program that uses robust quality improvement processes to continuously evaluate and improve the program over time, and more importantly, produce quality measures that indicate better health of individuals served by the program. Data from treatment planning, program operations, and quality measures will be used to establish both short and long-term goals for quality improvement. Each year, there will be one goal specific to improving SSCP’s Accountability Score for quality measures. The first quality initiative identified for BP1 is to track and improve Enrollee engagement.
The overarching goal of SSCP is to become a viable and valuable part of the healthcare system, recognized for helping individuals with the most complex needs attain healthier outcomes at reduced costs.
The greatest challenge to achieving our long-term goals is the financial incentives or disincentives in the healthcare system. An integrated model of care cannot be sustained by payment models that reward volume over value. The current fee-for-service structure does not provide financial incentives to communicate and collaborate across and between different systems. The financial viability of care coordination on behalf of people who need care across different providers and systems lies in a financial model that pays for better health outcomes rather than number of hours served.
Therefore, our plan for sustainability is to become an integral part of the larger healthcare system by providing a fast, streamlined pathway to clinical and social services for high need high cost individuals. According to the actuarial company Milliman, “a 10% reduction can be made in the excess healthcare costs of patients with comorbid psychiatric disorders via an effective integrated medical-behavioral health program.” This provides an incentive to ACOs to continue contracting with BH CPs to provide integrated care that keeps individuals healthier through primary and behavioral health care and avoids utilization of acute care services. Our value to ACOs will be our ability to prevent and divert over utilization of acute care services.