The MGB ACO contracts with community agencies to offer case coordination/care management services for certain high-risk MGB ACO members, the program is known as "Community Partners"

Background

The MassHealth Accountable Care Organization (ACO) program is a special MassHealth (Medicaid) program that allows funds to be used flexibly and, unlike traditional fee-for-service coverage models, includes provider incentives to address preventative care and the social determinants of health.

How do I know if my patient is a member of the MGB ACO?

 Check Epic for insurance status:

 

• Eligibility
• Enrolled in Mass General Brigham MassHealth ACO
  • (Note: If enrolled in a non-MGB ACO they may qualify for similar services through their ACO; they may inquire via their PCP)
• Complex needs with high healthcare utilization and comorbidities
• And ONE of the following:
• Behavioral Health (BH) CPs - For patients (21- 64 years) who need support in managing their mental/behavioral health conditions and/or substance use disorder.
• Long Term Services & Supports (LTSS) CPs - For patients (3-64 years) with chronic illness and/or disabilities needing services such as hospice, adult day health, DMEs, ABA therapy, etc.
• How it Works
• Eligible MassHealth members who are referred to the program are assigned a Community Partner near their home address.
• The Community Partner assigns a care coordinator/manager who engages members to enroll them, complete assessments and develop care plans directed by patient’s self-reported needs.
• Care plans are forwarded to patient’s PCP for review and approval through the MGH Key Contact.
• We encourage outreach to the Community Partner if PCP wishes to engage them for assistance.
• To Refer
• email phscommunitypartners@partners.org. Epic referral option is in the works.
• Source and More Information
  • https://apollo.massgeneral.org/medicaid-aco/wp-content/uploads/sites/9/2023/01/Community-Partners_one-Pager-final-7202021.pdf

Community Partners Already Involved? Find Organization Contact

For all patients engaged in CP, you should see a care coordination note in their chart outlining enrollment/disenrollment status, the assigned care coordinator, and the general organization contact. The care plan should also be uploaded to the media tab in the patient’s chart.

Example of patient cc note:

There may be a lag between when the change is made and when we hear of the change. If you find out that the information on the care coordination note is inaccurate or has changed, please update the patient care coordination note and let Saja Alani, MPH, know via email: MGHCommunityPartners@partners.org

-Source: email from Saja Alani to MGH Outreach & Resource navigation group, 5/22/23.

 

Comparison Grid: services available through MGH iCMP, iCMP Plus, Community Partners and SDH CHWs/Navigators (note for iCMP, referral usually must come from the PCP.)