Care Coordination and Integration
HMA brings practical experience to help organizations to design and implement care coordination and to deliver integrated care. Our team of experts has worked within organizations doing this work and we understand the challenge of implementing new work flows in busy practices. Our team brings deep knowledge of primary care and behavioral health practices both operationally and culturally that supports bringing ACOs and Community Partners (CPs) together.
Particular areas where we provide support include:
Support for defining best practices in care coordination and care management, adapted to local cultures and organizations
Models for integrating care coordination across traditional siloes:
Training and implementation plans to develop functional, resilient teams
Support for operational and cultural integration between ACOs and CPs.
For more information, contact [email protected]
Meet Our Team
The HMA Care Coordination and Care Integration Domain Team, which is led by Lisa Whittemore, includes local and national experts with experience working with providers to design and execute training objectives.
View Our Recent Work
Health Policy Commission PCMH Learning Collaboratives and Practice Coaching
- Project Challenge or Goals: Assist primary care practices of various sizes and structures to advance toward more integrated models with behavioral health care and achieve PCMH PRIME Certification from the Health Policy Commission. Model included use of a combination of large-scale Learning Collaboratives to teach concepts of integrated care and change management, and customized Practice Coaching based on unique goals for integrated care
- Project Period: 2017-present
- Project Description: PCMH PRIME is a certification program designed and implemented by the Massachusetts Health Policy Commission to recognize primary care practices who excel at integrating behavioral health care into primary care for their members. HMA provides technical assistance to practices on the Pathway to PCMH PRIME Certification, including primary care practices working to enhance referral relationships with behavioral health (BH) providers, practices working on improving screening protocols or care management processes for BH conditions within their existing infrastructure, practices implementing tele-behavioral health programs or other innovations to improve the availability of BH care in the primary care context, or practices implementing the Collaborative Care Model or other advanced models of integration. The program included large-scale Learning Collaboratives to promote awareness of best practices in BH integration and build the skills of the participants to implement changes in processes to achieve goals. HMA also offers coaching to all practices in the program to help them achieve their individual goals related to enhancing BH integration in primary care
- Project Achievements: Most practices in the first cohort of the program achieved PCMH PRIME Certification and reported that the technical assistance program was helpful to achieving their integration goals. The individual practice coaching was rated highly by practice participants
Support Integration of ACO and Community Partners for MassHealth ACO Implementation
- Project Challenge or Goals: Assist a multi-site CHC in achieving readiness for MassHealth ACO program
- Project Period: January 2016 – January 2017 (for primary scope of work; project remains active)
- Project Description: A contract to improve MCHC’s readiness to accept Alternative Payment Methods, focusing on both its clinical and financial processes, data and analytics capabilities, and associated required workflow and related information system changes
- Project Achievements: HMA provided an evaluation of the current environment, a gap analysis, and support for the implementation of an approved work plan
Support to Develop Model of Care, Program Design for Behavioral Health Community Partner Program
- Project Challenge or Goals: Lead initial program development, including refining the model of care.
- Project Period: November 2017 – February 2018
- Project Description: Working closely with the leadership and clinical staff of all affiliated partners of the BH CP, consultant facilitated processes to refine the model of care and program features to launch the program. Appointed as “Acting Program Director” until new staff hired to run the program
- Project Achievements: Successful initial launch of the program immediately following selection by EOHHS. Consultant leveraged best practices, knowledge of the ACO environment and awareness of the CP program design and requirements to assist with the development of the initial model of care and staged hiring plan, approved PY0 budget, approved quality management plan and governance model for the organization