What is a Community Partner (CP)?
Community Partners are behavioral health and long term support service organizations that coordinate care for individuals covered through Medicaid/MassHealth who have severe mental illness, a developmental disability and/or the elderly who also have a history of significant medical claims and a high cost of care. The purpose of a CP is to assist people from these populations in adhering to the care plans of their medical and behavioral health providers.
What is Care Coordination?
As the name implies, Care Coordination is a mechanism that ensures a patient’s overall health needs are being met, with the right care is being delivered in the right place at the right time by the right person. A Care Coordination team, comprised of a multidisciplinary group of nurses, clinicians and bachelor’s level care providers, creates individualized plans to support to MassHealth enrollees with complex medical, behavioral health and long term service needs. The team coordinates communication between the individual’s medical and community-based service providers and connects people to resources to help them meet their health and wellness goals.
Why is Care Coordination so important now?
Massachusetts has instituted health care reform of the Medicaid (MassHealth) care system. Effective March 1, 2018, Massachusetts established Accountable Care Organizations (ACOs) that are hospitals and other health care providers who are paid to care for entire populations of individuals on MassHealth, rather than the former per person fee-for-service system. Given the funding change, ACOs now have the financial incentive to prevent illness and improve people’s health to reduce the cost of medical care. To support these ACOs, Massachusetts has also created a system of Community Partners (CPs) to support the ACOs in these efforts.
What is Innovative Care Partners?
Innovative Care Partners, LLC (ICP) is a Community Partner servicing MassHealth enrollees in the four counties of Western Massachusetts. It is a limited liability company established by three long-standing, well-respected local behavioral health and social service agencies to specifically respond to the needs of the MassHealth population in managing health and controlling costs. Center for Human Development (CHD), Gándara Center, and ServiceNet formed ICP as a stand-alone company to get the best health outcomes for enrollees through a transformative, cutting-edge approach to health care reform.
How does ICP Help ACOs?
ICP knows the MassHealth population and knows they can be challenging to serve, but we are uniquely qualified to reach them with cultural competence to deliver coordination of care with human service.
Patients with severe or multiple health conditions and functional limitations are more likely to go to hospitals, emergency rooms and long-term care facilities. They are also more likely to need supportive services to help with activities of daily living or to arrange for transportation. As a result, they are more vulnerable to fragmented care, which contributes to suboptimal outcomes. ICP leverages ACOs’ capacity for care using our organization’s capacity for care management.
How does ICP promote better health outcomes?
ICP anticipates client needs, adapts to changing circumstances, and leverages resources to promote better health outcomes, including these:
- Person-centered planning focused on each patient’s unique health concerns
- Individualized care management to improve follow up and follow through in care planning
- Cultural competency for better understanding of care planning and greater patient compliance
- Reduced emergency room utilization that lowers the cost of non-emergency care
- Coordinated care planning that keeps the “human” in human services
Who are the organizations behind Innovative Care Partners?
- CHD (Center for Human Development): Founded in 1972, CHD is a CARF-accredited organization that provides a broad range of high quality, community-oriented human services to 17,000 children, adolescents, adults, and families each year. CHD is dedicated to promoting, enhancing and protecting the dignity and welfare of people in need. chd.org
- Gandara Center: Established in 1977, the Gandara Center provides outpatient mental health and substance use services to the growing and largely unserved Hispanic community in Western Massachusetts. The organization promotes well-being through innovative, culturally competent behavioral health, prevention and educational services. gandaracenter.org
- ServiceNet: Tracing its roots to 1965, ServiceNet serves people living with mental illness, developmental disability or autism, brain injury, or substance use or addiction issues. ServiceNet works with individuals and families, people who require continuing support, and others who need short-term counseling. servicenet.org
Robert Stover, Program Manager for CHD’s Not Bread Alone, is a practical man. As a matter of routine, he focuses on logistical concerns of preparing good food and serving satisfying meals to anyone who is hungry, three times a week. But he also embodies qualities of a caregiver, and sometimes the care he and his staff provide for guests takes on added urgency.
“If we are Not Bread Alone,” Stover asked, “then what else are we, in addition to bread?” As it turns out, one answer to that question is “life savers.”
For decades, a man we’ll call “Gary” has been a regular guest at Not Bread Alone, CHD’s community meals program at First Congregational Church in Amherst. “I’m under the impression that he has been living outside for decades,” said Stover. “He’s a big, burly guy with a bushy mustache and he dresses for the cold. He carries his life on his back in a huge, bulging backpack that is always with him. He may have a friend with an apartment where he can crash occasionally, but he’s usually outside.”
One day recently, it helped that Stover knew something about Gary. “I got the sensation that he wasn’t really eating much,” Stover recalled. “I noticed he was going back and forth to what I presumed was the bathroom. Well, somebody came to me and said, ‘Bob, we have to call an ambulance, Gary has passed out!’ While someone went for a phone, I went to Gary. He was conscious but not well. I asked if it was OK to call him an ambulance and he said it was. I dialed 911 and explained the situation, that his breathing was labored and he was pale and in pain.”
A police officer arrived first and an ambulance crew soon after. Gary was placed onto a stretcher and transported to the hospital. A couple days later, Stover received an email from a colleague at another local meals program where Gary regularly goes. She hadn’t seen Gary for days and was concerned. Stover explained what happened and his colleague followed up with local hospitals. “He’s at Baystate now,” she replied. “Sounding tired but OK. Ruptured aortic aneurysm. You saved his life.”
CHD’s motto is Positively Life Changing, but in this case it was Positively Life SAVING! If Gary hadn’t gone to Not Bread Alone for a meal that afternoon, he may well have ended up dying alone. But as this story is published, Gary is recovering from open-heart surgery and at a nursing home for rest and rehabilitation.
“Most people who come for a meal at Not Bread Alone worry about scarcity,” said Stover. “It just overrules any other thoughts. So I try to convince our guests that they aren’t receiving charity. They are not objects of pity, but fellow human beings. They deserve food that is good. They deserve to be here enjoying a satisfying meal. We’re glad it’s available and we’re glad they’re here.”
More than a few people daydream about going fishing. Jessica Levine, Program Manager for CHD Disability Resources, has a sticky-note on the wall above her desk for a daily reminder about just that topic. That’s because fishing is one of many outdoor activities that Levine and the staff of Disability Resources make accessible for persons with disabilities, including kids, adults and veterans.
“I try to take a well-rounded approach to Disability Resources programming,” Levine explains. “Fishing can be incredibly social and laid back if you allow it to be, but you need the right channels and resources to make it accessible and inclusive. We pulled those channels and resources together to create Gone Fishing, which has become one of the most popular programs we offer.”
Levine points out that, for people with disabilities, fishing involves two key components: licensing and accessibility. “Massachusetts fishing licenses are free for life for persons with disabilities,” she explains. “All that’s required is a state-issued form and a physician’s signature, so that solves the licensing component.”
To identify locations where fishing is accessible to someone in a wheelchair, Disability Resources enlisted the help of Adapt Outdoors, an organization that specializes in supporting people with disabilities and veterans in their pursuit of enjoying the outdoors. “We learned that fish and game clubs are private organizations and most are interested in finding ways to give something back to their communities,” says Levine. “For example, the West Springfield Fish and Game Club has a lake on site that is stocked with fish and the setting is highly accessible to anyone who uses a wheelchair, as some of our program participants do. Adapt Outdoors provides the gear and bait, which is a huge benefit for parents who don’t have to lug around fishing poles and tackle boxes.”
Gone Fishing participants include individuals who have a variety of disabilities, including those who have an intellectual disability, developmental disability and/or visual impairment. Some are wheelchair users, some aren’t. Some are also siblings of individuals with a disability.
“Participants typically catch sunfish and trout,” says Levine, “and we do all catch and release. These events also include a cookout so they develop organically into a family night. We have some amazing volunteers who help participants fish and also prepare food for the cookout. The lake has fish, the poles are ready to go, the hooks are ready, the worms are there—all you have to do is show up!”
For 2018, Gone Fishing includes two eight-week sessions. The Spring session is April 25 through June 13, and the Summer session is July 18 through September 5. Each event takes place on a Wednesday evening from 5:00 to 7:00 p.m. at the West Springfield Fish and Game Club, 329 Garden Street in Feeding Hills. The program is open to the public. Cost for the full 8-week session is $20 per individual ($35 per family of 3) for Disability Resources members, and $30 per individual ($50 per family of 3) for nonmembers. A $50 annual membership in Disability Resources provides access to free programming and community outreach plus reduced cost for paid programming such as Gone Fishing.
“You don’t have to be a member, you just have to be interested in some fun and accessible outdoor activity,” Levine says. “At the end of the day, we are about giving people access to great recreation.”
To learn more, visit the CHD Disability Resources page on Facebook or contact Jessica Levine, Program Manager for CHD Disability Resources at 413-788-9695 or firstname.lastname@example.org.
“There is a lot that happens around the world we cannot control. We cannot stop earthquakes, we cannot prevent droughts and we cannot prevent all conflicts, but when we know where the hungry, the homeless and the sick exist, then we can help.” – Jan Schakowsky
To help the homeless population of Waterbury, Center for Human Development (CHD) has a unique program called the CHD Hospitality Center, located at 693 East Main St., Waterbury, CT, The Hospitality Center offers an array of services to help the city’s homeless move towards their endeavors and their goals of employment and housing.
Monday through Friday from 7:30 a.m. to 3:00 p.m., participants are welcomed to a safe environment where staff are compassionate, understanding, and motivating. They can take respite from the extreme weather, do laundry, take showers, and socialize with their peers. They can also use a multitude of in-kind services from local providers such as medical, legal, housing, employment, mental health, substance abuse, donated clothing, counseling, vocational training, and many others.
Every donation that comes into the CHD Hospitality Center goes right back out to help a truly appreciative and needy population.
Donations of every shape and size are welcome! Clothing, volunteers, financial contributions. We invite you to tour the CHD Hospitality Center any time!
To learn more about the services that CHD offers, please visit http://chd.org/adult-services/connecticut-programs/hospitality-center/