Innovative Care Partners is a partnership between CHD, ServiceNet, and Gandara Center—and an example of how effective care coordination has been playing a vital role in Massachusetts’ health care reform initiative.
In 2018, the state launched Innovative Care Partners (ICP)—one of 27 “Community Partners” across Massachusetts—with the goal of having area health providers deliver exceptional care coordination services to meet MassHealth enrollees’ health care needs and to rein in costs. This endeavor was designed to integrate medical, behavioral health, and long-term services by improving communication between those providing care.
“It was also designed to help address social determinants of health, such as poverty, substandard housing, poor access to transportation, poor access to social services, and food insecurity,” said CHD Vice President of Health Care Integration Dan Quinn.
ICP provides care coordination through Massachusetts’ Community Partnership program, which was reduced to 20 Community Partners in 2022. These entities work with Accountable Care Organizations (ACOs) to deliver services.
Community Partners make sure that the ACOs—teams of doctors, nurses, and other providers, including therapists and psychiatrists—are all on the same page providing collaborative care.
“About 40,000 MassHealth members have been assigned to Community Partners statewide, and ICP provides care integration to more than 3,000 of them,” said Quinn. “These are very complex cases, psychiatrically and medically, and our job is to coordinate with the ACOs to reduce their cost of care and improve their health outcomes.”
In the state’s new “capitation” payment system, providers are not paid in the old fee-for-service model, but in a fixed amount for each person they treat, with reimbursement based on value, not volume—that is, providers are rewarded for better cost and outcomes vs. the old system, in which they were paid for the number of patient office and hospital visits.
Award-Winning Work
This seven-year-old Massachusetts health reform model has seen promising results, and so has ICP. Since its implementation, the Community Partners program has shown a reduction in emergency department visits, behavioral health admissions, and care costs across the state. ICP, because of its success, was invited to the National Council for Mental Wellbeing’s annual conference in 2022, where Quinn and ICP Director of Healthcare Integration Jennifer Genovese delivered a presentation entitled “Achieving Improved Health Outcomes and Reduced Cost of Care as a Behavioral Health Home.”
They pointed out that ICP had the lowest risk-adjusted cost of care compared to all other behavioral health homes, which are programs designed to integrate medical services and care management with mental health care.
In 2023, ICP earned the Excellence in Outcomes award from the Association of Behavioral Healthcare for having substantially lower avoidable utilization rates for hospitalizations and emergency department visits than other behavioral health community partners. ICP received the accolade because in 2022, for individuals they served, medical admissions were 6.1 percent lower, behavioral health admissions were 38 percent lower, and emergency department visits were 11.7 percent lower.
“I think we’ve been innovative—and a state leader—in a lot of ways,” said Quinn. “We’ve been very successful managing by data—our staff get automated reports that integrate medical claims, electronic medical record data, and admission, discharge and transfer systems data, so we are informed every day when someone has gone to the emergency department, or someone has been admitted to a hospital.”
In fact, Quinn and ICP Director of Quality Improvement Deirdre Moraes delivered a presentation in October 2024 at the Camden Coalition’s national conference in Pittsburgh to discuss how analytics, powered by artificial intelligence, can help improve health outcomes. The Camden Coalition focuses on enhancing care for patients with complex needs. “We discussed our readmission predictor—we developed a way that artificial intelligence can read our electronic medical record data and predict when someone is at risk of being readmitted to the hospital within 30 days,” said Quinn. “When we get automated popup reminders, we might call the person and ask if they feel OK, or if they missed a medication dosage, or if they missed a doctor’s appointment.” This results in reducing avoidable hospital utilization.
ICP also delivered a presentation at the Camden Coalition’s 2025 national conference in Portland, OR. The presentation, entitled Improving Health Outcomes in Complex Care Using Care Coordination, discussed ICP care coordination services and their impact on clients.
A New Age in Health Care
In 2018, this massive MassHealth restructuring required extensive outreach to members, and it still does. Genovese likes to describe ICP’s enrollment specialists as their “little detectives” finding clients, some of whom are transient or have fallen through the cracks for a variety of reasons—society’s most vulnerable members who may lack access to a computer or phone, have no or unstable housing, or have limited English proficiency.
“This involves cold-calling and door-knocking all over the western region,” said Genovese. “Once they agree to get enrolled, each one of them is assigned a care coordinator, and they’re engaged in a care plan. We build that relationship and use motivational interviewing. We ask them what they need. For example, we’ll say, ‘Wouldn’t it be great if you took your medications regularly and you felt better and stayed out of the hospital?’ And if they report to us that their medications don’t make them feel good, we can build the connection to their doctor, and tell their doctor, ‘Maybe we can figure out a better plan of attack.’”
Quinn likens ICP’s approach to “using 21st century technology with some 1970s-style clinical interventions.”
ICP care coordinators also advocate for enrollees across the health care system—and beyond. For example, Holyoke resident Lorraine Ivelisse, who was born with cerebral palsy and uses a wheelchair, relies on her care coordinator to stick up for her when she deals with medical professionals. “Sometimes the doctors don’t listen to me—they ignore me, or minimize my problem, and they don’t take me seriously,” she said. “You can see it in their demeanor and hear it in the tone of their voice. But with my care coordinator Tammy Bishop helping me, I feel valued. My needs are met. It feels so good to have somebody supporting me.”
Bishop and fellow care coordinators typically go above and beyond for their clients. Ivelisse requires the use of catheters, but once there was a problem with a delivery, and the medical equipment company was less than responsive to her calls. “They told me I have to come pick them up, and I don’t drive,” she said. If a patient has no other choice than to use old catheters, they’re at risk of a urinary tract infection and ending up in the emergency room. However, Bishop called the company. “I got them delivered to my door the same day,” said Ivelisse.
Another Holyoke resident, Rejine Caraballo, is a sarcoma cancer survivor who had her right leg amputated 12 years ago, and she also uses a wheelchair. She has had similar frustrations with medical professionals. “But when I have my care coordinator speak up for me, it’s a different story,” she said. Care coordinators also assist members with health-related societal needs, such as housing and nutrition. Caraballo’s care coordinator, for instance, helped her fill out her affordable housing application, and Bishop ensures that Ivelisse’s two children with learning disabilities get the services they need in school.
“A high level of advocacy is a key feature of what we do,” said Quinn, noting that social determinants of health affect a wide range of health risks and outcomes—these causal factors include accessibility to education. He recalls an enrollee whose nine-year-old child is on the autism spectrum and is non-verbal. “For three years she unsuccessfully tried to get her child American Sign Language classes, and finally her care coordinator went to the child’s IEP meeting and asked the people around the table about providing the ASL classes, and they said, ‘OK, we’ll write that in right now.’ The woman was in tears of joy telling me this,” said Quinn. “We have about 400 children in our program, and many of these people don’t feel seen or heard, so health equity is a major goal in this program.”
The Future
In 2022, the Centers for Medicare and Medicaid Services, the federal agency that oversees Medicaid, approved Massachusetts’ request for a five-year extension to its health program innovations, resulting in ICP being awarded five-year community partner contracts. These contracts allow ICP to continue serving more than 3,000 MassHealth members and build on its successes in coordinating care and addressing health-related social needs.
For the next two years, the goals of the state’s Community Partners program include reaffirming MassHealth’s commitment to community-based outreach and care coordination for the highest-risk members, and strengthening Community Partners’ accountability for outcomes—accomplishments that Quinn is confident can continue to happen. “I believe we’ve gotten a lot better at care coordination—getting the right care delivered in the right time at the right place and by the right person,” he said. “Patients’ health has improved, and costs have decreased.”