A. Community Partner Composition
The Southeast Community Partnership, LLC (SCP) is a newly formed limited liability company with two consortium partners, South Shore Mental Health (SSMH) and Gosnold, Inc. and one Affiliated Partner, Family Continuity (FC). Together, this partnership represents over 169 combined years of in-depth knowledge and expertise serving people with substance use disorders and mental health conditions. SCP promotes optimal health outcomes for adults with complex mental, physical, and social challenges through a responsive and collaborative system of care. 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.
Gosnold, Inc. is a private, nonprofit service agency in Southeastern Massachusetts providing a comprehensive range of addiction services from inpatient detoxification to residential rehabilitation to convenient outpatient clinics to extended sober living. Since 1972, Gosnold’s innovative programming and commitment to excellence has made it the program of choice for those affected by substance use disorders and co-occurring substance use and mental health conditions.
Family Continuity was founded in 1985 and supports the behavioral health needs of individuals and families through community and home-based support, and outpatient mental health and substance use clinics. FC provides a Gosnold of emotional, developmental, and behavioral programs for children, adolescents, adults, couples, families, and seniors.
Together, SSMH, Gosnold, and FC 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 Southern Region Service Area, including Attleboro, Barnstable, Brockton, Fall River, Falmouth, Nantucket, New Bedford, Oak Bluffs, Orleans, Plymouth, Taunton, and Wareham. The SCP team has substantial experience and expertise serving individuals with serious and persistent mental illness, substance use disorders, co-occurring disorders, and the full range of behavioral health conditions. SSMH operates three outpatient clinics in Quincy, Plymouth, and Wareham, residential programs, and mobile services in homes, schools, childcare centers, and other community settings throughout southeastern Massachusetts. Gosnold serves residents in Southeastern Massachusetts who have substance use disorders and/or co-occurring 2 substance use and mental health disorders. On Cape Cod, Gosnold operates the Gosnold Treatment Center and Miller and Emerson Houses in Falmouth and an inpatient rehabilitation in Cataumet. Gosnold also offers medication assisted treatment and counseling in seven outpatient clinics in Centerville, Falmouth, Orleans, Nantucket, North Dartmouth, Provincetown, and Stoughton, as well as Partial Hospitalization Programs in Centerville and Stoughton. FC’s Family Partner Program in Hyannis was the first family partner program to open in 2009 and currently works with over 150 families.
The Southeastern region is ethnically and culturally diverse. The four largest cities in Southeastern Massachusetts, namely Brockton, New Bedford, Taunton, and Fall River, also have the strongest Portuguese and Cape Verdean presence. In 2000, 43.9% of Fall River residents identified as being of Portuguese heritage which is the highest percentage of Portuguese Americans in the country. There are smaller, but significant presences of other Portuguese-speaking communities, such as other Azorean Islanders, Portuguese from mainland Portugal, Madeirans, Cape Verdeans, Brazilians, and Angolans. In 2000 New Bedford had the second highest percentage of Portuguese Americans with 38.6% of residents reporting that ancestry. New Bedford is also 8.0% Cape Verdean, 4.39% African American and 7.1% Puerto Rican, and 3% Hispanics. All three partner agencies have staff who represent these cultures and speak their respective languages. Regardless of ethnicity or language spoken, the SCP serves all people with complex physical, mental, and social needs.
C. Overview of Five-Year Business Plan
SCP, LLS is led by a Board of Directors comprised of senior leadership in SSMH and Gosnold 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 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 five-year contract, SCP 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 SCP’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, SCP has purchased a care management software platform that provides secure communication between ACOs, MCOs, PCPs, SCP, and Enrollees’ care team members, called Care Navigator©. SCP 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 SCP 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 3 BP 5: Continue system adaptation to improve communication, information sharing, and integration of services
Workforce development:
The long-term goal of SCP’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, SCP has developed a workforce development strategy between SSMH, Gosnold, and FC 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 SCP staff using the standardized, comprehensive curriculum developed during pre-budget period
BP 2: Increase cultural and linguistic capacity of SCP 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
Program administration:
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 all short and long-term goals for quality improvement. Each year, there will be one goal specific to improving SCP’s Accountability Score for quality measures. The first quality initiative identified for BP1 is to track and improve Enrollee engagement.
The overarching goal of SCP 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 4 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.