Vicki Ritterband, Interim Vital Signs Editor
It’s challenging to maintain good control of your diabetes when you have limited access to fresh fruits and vegetables and no place to refrigerate your insulin. And if you’re worried about where you’ll sleep on any given night, getting an annual mammogram is probably low on your to-do list.
In an effort to encourage caregivers to address patients’ social needs in tandem with their medical ones, MassHealth has undergone one of its most ambitious restructuring in decades. As of spring 2018, more than 850,000 members are now enrolled in one of 17 MassHealth accountable care organizations (ACOs) — groups of physicians, hospitals, and other health care providers that collaborate to deliver coordinated, high-quality care to their patients, with reimbursement based on value, not volume. Under the new model, ACOs contract with MassHealth to provide members with medical and behavioral health care and addiction treatment. MassHealth also launched the Community Partners (CP) program in July 2018. CPs are community-based organizations with expertise in working with members with severe behavioral health and social challenges, as well as long-term support needs. CPs partner with ACOs and managed care organizations to provide intensive care coordination for these members. “The ACO model we have rolled out asks for an unprecedented level of joint care planning, coordination, and integration among primary care, behavioral health providers, and community partners. It’s a big paradigm shift,” said Daniel Tsai, assistant secretary for MassHealth and Medicaid director for the Commonwealth.
Health-Related Social Needs
Daniel Tsai
As part of their MassHealth contracts, ACOs must query patients about those needs — called health-related social needs in MassHealth parlance — that could have a profound impact on their health, including housing, nutrition, safety and security, and transportation. “You can’t address issues from a cost, quality, and care standpoint for our most complex members without addressing gaps in their behavioral health care and health-related social needs,” explains Tsai. “We’re hearing anecdotally that the ACOs are uncovering a lot of unmet needs and that’s exciting and terrifying. Now they have to figure out how to meet those needs.” ACOs are already collaborating with community partners — including addiction treatment programs, elder services, and housing organizations — to address their patients’ challenges.
MassHealth applied for and received an infusion of $1.8 billion in federal funds, called Delivery System Reform Incentive Payments (DSRIP), to support its redesign to an ACO-centered system. Beginning in 2020, MassHealth ACOs will be eligible to use some of that money to assist patients with their housing and nutritional needs.
Vital Signs recently sat down with Sarika Aggarwal, MD, former chief medical officer of Beth Israel
Deaconess Care Organization (BIDCO). BIDCO, recently renamed Beth Israel Lahey Performance Network, created an ACO plan called Tufts Health Together with BIDCO — one of the state’s 17 MassHealth ACOs. We asked Dr. Aggarwal about how Tufts Health Together with BIDCO will use its DSRIP funds as well as other aspects of creating an ACO that address patients’ social determinants of health.
VS Can you tell us a little about the Tufts Health Together with BIDCO ACO?
Sarika Aggarwal, MD
Aggarwal Tufts Health Together with BIDCO is a partnership plan in which the ACO providers and hospitals work together to provide an integrated multidisciplinary approach to the care of MassHealth members. Our strategy is to leverage existing infrastructure and use Delivery System Reform Incentive Payments to make targeted investments to improve health outcomes and bend the cost of care curve for this population. Our investment priorities included four main categories: care management and population health management resources and services, information technology and workforce development, integration of behavioral health and social determinants of health into primary care, and the development and integration of data and analytic reporting functionality across the payer and provider systems. Like the other MassHealth ACOs, we’ve been up and running since March 1, 2018. Our membership numbers fluctuate, but we generally care for between 35,000 and 38,000 people.
VS MassHealth ACOs are required to screen patients for their health-related social needs. Which tool are you using to gather the data and how are you doing it?
Aggarwal Tufts Health Together with BIDCO is required to screen patients for social determinants of health as a quality metric. We are also committed to screening based on our belief in the whole person care model as well as the increasing body of evidence showing the impact of social determinants on health outcomes. Our health plan partner began offering screening to the ACO members at the start of the program. In order to improve screening and referral, it was important that this was incorporated into the practice workflow.
As part of our DSRIP strategy, we implemented the electronic medical record (EMR) build of the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences), a state-validated screening tool. This tool was chosen because it used national and regional core measures, it was informed by research, and PRAPARE templates existed for several of the BIDCO EMRs. BIDCO primary care physicians use six different EMRs, and this number increases significantly when you include multiple versions as well as our specialists’ EMRs. Since PRAPARE EMR templates already existed for two of our three main primary care EMRs, our strategy was to use this tool to automate the screening and build the training and referral processes in the primary care practices in the initial phase, while incorporating screening at other sites in subsequent years.
Part of the automation was to ensure this structured data was incorporated into our data warehouse, which already integrated claims and clinical data, in order to enhance future risk stratification models for our clinical programs.
Our EMR build started in 2018 and we began the first pilot at our South Cove Community Health Center, which has multiple sites in and around Boston. About 99 percent of the MassHealth population there is Asian. The tool was translated into traditional Chinese and the center began the screening and referral process manually, inputting the information into the EMR tool. Subsequently, we began other pilots and have started disseminating the training to other primary care sites using lessons learned from our pilot sites.
VS What does the tool ask about?
Aggarwal The original tool has several national core measures, including questions on race, language, ethnicity, education, employment, housing and food stability, transportation, social supports, and safety. It also includes optional measures such as incarceration and refugee status. The tool included all the MassHealth key focus areas.
VS Have there been any implementation challenges?
Aggarwal A major initial challenge was staffs’ hesitation to ask certain questions as well as patients’ reluctance to answer them — about things such as refugee and incarceration status. Other challenges included the length of the original PRAPARE tool and some practice sites’ difficulty making referrals because of lack of knowledge or time. This was a challenge particularly for smaller practices. We also found that not all the patients accepted an action plan by the practice if a need was determined.
To respond to some of these challenges, we decided to focus on questions in the PRAPARE that aligned with the key areas determined by MassHealth. Our workaround included re-training the practices to ask only those questions that we determined were the MassHealth focus domains. We also incorporated a patient question at the end of the tool allowing the patient to determine whether he or she needed help with any of the areas determined as a need. In addition to screening education for all practice staff, we have built community resource directories and training programs and expanded existing resources to meet patient referral needs.
VS Can you tell us about Tufts Health Together with BIDCO’s plans for the DSRIP funds?
Aggarwal MassHealth has begun to give us guidelines on the flexible service DSRIP program starting in 2020. This program will fund solutions to food and housing insecurity in high-risk patients. Along with our health plan partner, we have begun the process of analyzing our patient cost, utilization, disease co-morbidity, and social determinant of health data to figure out where we will have maximum impact, which cohort of patients will be eligible, and which programs on housing and food insecurity will best serve our patients’ needs. We are having discussions with community service organizations as well as our community partners to build our strategy around these funds.
Potentially we are looking at patients in the community partner program who are high utilizers and have concomitant chronic medical and behavioral diseases such as diabetes, asthma, COPD, and bipolar disorder as our cohort for this program. Our plan is to implement disease management education in addition to serving the patients’ food and housing needs. We have also planned in-house training to address gaps in these areas for all our clinical and non-clinical staff.
VS What is your vision of success for Tufts Health Together with BIDCO?
Aggarwal Our vision is to create communities of care across BIDCO where the providers, health plan, and community partners work collaboratively to improve access, communication, data integration, coordination of processes and resources, and integration of medical, behavioral, and social care to improve patient health outcomes.
