Care Coordination and Integration

The Massachusetts eHealth Collaborative (MAeHC) helps healthcare organizations integrate care among previously-siloed care teams. We assist integrated core teams of primary care, mental health, substance use disorder, and community supports providers to begin working together, often for the first time, to orchestrate care delivery for their most complex Medicaid members. Our care coordination technical assistance approach is comprehensive.

  1. Patient-Centered Process Mapping: Support for new integrated care process development and mapping

  2. Analysis to Identify Organizations and Teams: Identification of the specific organization and team member ‘constellation’ that surrounds the Medicaid member using analysis of available data

  3. Cross-Team Integration Planning: Outreach and introductions of team members to one another and facilitation of cross-team integration planning and deployment

  4. Patient Privacy Navigation: Review of the patient privacy laws and rules that accompany care integration for members with sensitive conditions (e.g., Part 2 SUD treatment, mental health treatment, HIV)

  5. Shared Care Planning Tools: Set up and deployment of shared care plan charting tools and processes

  6. Launch Integrated Care Program: Support to stand up and operate an integrated care program

MAeHC deploys pragmatic technical support that is grounded in evidence and honed through years of shoulder-to-shoulder work with providers. We draw primarily on the following evidence and approaches:

  • AHRQ Integration Framework – For integration of primary care and behavioral health
  • NCQA Patient Centered Medical Home – For integration of primary care and behavioral health
  • Critical Time Intervention – For re-integration of complex Medicaid members from acute settings (or incarceration) to a team of community supports

Example Project:

MAeHC will assist with optimization and customization of EHRs, policy and process development, definition and monitoring of high-risk population for care management. MAeHC will involve all staff levels to insure proper education, alignment and understanding of the processes to ensure effective team-based care, care planning, and tracking. MAeHC routinely provides Patient Centered Medical Home (PCMH) Services that include education on the standards and guidelines, practice level assessment to determine readiness, gap analysis, assistance with workflow development to support PCMH model of care.  This model can greatly enhance the care coordination and data integration throughout an ACO.