Health

HE A LTH • Summer 2019 17 Wraparound care ACOs are in the first of a five-year plan for MassHealth – the state's Medicaid program – to invest more than $400 million in wraparound ser- vices for patients with more complex situations. It's an understanding that health determinants happen outside of a medical exam room, with a goal to coordinate more preventative care, with better results and lower costs. Under the new model, MassHealth contracts with ACOs for health care, mental health care, treatment for sub- stance abuse, and with long-term ser- vices and support (LTSS) organizations for certain MassHealth members. Primary care providers handle the main responsibility for coordinating this care, which can sometimes include services not medical but contributing to a member's overall health, such as housing assistance or nutritional sup- port, said Chines. For example, Open Sky Community Services of Worcester, formerly The Bridge of Central Massachusetts and Alternatives Unlimited Inc., is a human services provider coordinating with Reliant as a trusted partner, said Chines, and has for a long time. The organization is a local leader in serving those with issues such as opioid addiction. President and CEO Ken Bates is on the Fallon 365 Joint Governance Board, with a voice at the table of the ACO. "We work on the evidence that coor- dination of non-medical drivers can significantly impact health care utiliza- tion," said Bates. "The partnership pro- vides care coordination and interven- tions to support enrollees so that they become clinically stable, acquire sus- tainable skills that improve their ability to navigate and engage with the health care delivery system, and are able to live in the community as fully and independently as possible." Partnerships with these service pro- viders form an important network of robust communication, Chines said. This helps when it comes time to track down a patient with a behavioral health issue who is disengaging, perhaps not showing up to medical appointments. Or when a patient has certain issues going on and needs to be transferred from one facility to the next. All systems go Fallon's Nickey is in a unique van- tage point to provide perspective on the Central Mass. ACO with Reliant, as he can compare it to others. His organization also is in ACOs with the Health Collaborative of the Berkshires and Wellforce, which includes partnerships with various facilities in Lowell and Tufts Medical Center in Boston. Those reporting sys- tems are not aligned with Fallon as the Reliant system is, meaning the ACO formation process has been less smooth in comparison, he said. Fallon actually uses the database of social service agencies developed by Reliant and UMass Medical when it needs to reach out to social service organizations. Nickey said he wishes all parts of the state had it. "It's a portal and helps you search by need in Central Mass.," he said. "They know who is out there." In addition to the relationship between Fallon and Reliant's superior IT infrastructure, the ACO was more streamlined as Fallon adopted a 90-day policy for patients when the ACO went into effect. Knowing the new system might be confusing, it simply honored all claims for 90 days. "In one day, 850,000 people found out that their insurance changed," Nickey said. "It's an anxious period of time if you have a surgery scheduled, or sometimes it's three months out to get a specialist visit." He said the 90-day policy mini- mized a lot of complications for the providers and members. "Our perspective was that someone approved what you had, so we are respecting their clinical judgment," Nickey said. Chines and Nickey credit MassHealth with being easy to work with on ACO implementation. Nickey said Fallon was prepared for more dis- ruption with the launch, and despite a few hiccups, the transition was more seamless than expected. Chines sees opportunity in ACOs and figuring out their best structure and operations methods. He said if there as any work that needs to be done, it's in the area of building bridg- es with human service providers to strengthen that network. "We can rethink ways we provide care" with ACOs, he said. "You have to look at the whole person. If we buy into the idea of social versus medical, we are missing the opportunity." Of the 1.8 million Massachusetts residents with MassHealth, 1.2 million are eligible to participate in an accountable care organization. MassHealth ACO enrollment Note: As of June 2018 Source: MassHealth Children with disabilities 488,678 113,812 554,196 634,213 31,504 Adults without disabilities Adults with disabilities Children without disabilities Seniors, people with private insurance or on MassHealth Limited Eligible for ACO Ineligible for ACO Ken Bates from Open Sky Community Services in Worcester has worked to integrate human services into accountable care organization benefits. PHOTO/BRAD KANE MassHealth Assistant Secretary Dan Tsai H

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