Community Partners Program
For Tufts Health Together
MassHealth will identify members of Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) members for eligibility for referral to the Community Partners (CPs) Program. CPs are organizations experienced with behavioral health (BH) or long-term services and supports (LTSS).
CPs will partner with MCOs and ACPPs to coordinate and manage care for certain CP-eligible Tufts Health Together members.
BH community partners (BH CPs) provide care management and care coordination support (including coordination of physical and BH needs) to eligible Tufts Health Together members with significant BH needs. LTSS community partners (LTSS CPs) provide LTSS care coordination and navigation to eligible Tufts Health Together members with complex LTSS needs.
The Massachusetts Executive Office of Health and Human Services (EOHHS) has contracted with 18 BH CPs and 9 LTSS CPs throughout the state to service MassHealth members from all MA communities. Tufts Health Plan care managers and care coordinators will work closely with these 27 CPs to ensure members working with CPs have the necessary support they need.
BH CP care coordinators will engage BH CP-referred members to complete a comprehensive assessment, including a social services assessment of needs, and develop a member-centered treatment plan. Tufts Health Plan care managers will also engage LTSS CP-referred members to complete a comprehensive assessment and member-centered care plan, which will be shared with the LTSS CP. The LTSS CP care coordinator will engage LTSS CP-referred members to assess social services needs and to develop a member-centered LTSS care plan.
What is the member's PCP's role with the CP?
As part of this CPs Program, the member’s PCP is responsible for:
- Participating on the member’s care team
- All members of the care team are expected to communicate frequently and effectively regarding changes in the member’s physical or behavioral health, LTSS or social service needs, updates to the member’s care plan, and care plan implementation.
- The member’s PCP or front-line staff at the PCP’s practice participate in the member’s care team, led by either the BH CP care coordinator or Tufts Health Plan care manager, and is actively engaged during a member’s care transitions (e.g., discharge from inpatient admission).
- Reviewing and approving the member’s treatment plan (from a BH CP) and/or care plan and LTSS care plan (from an LTSS CP)
- Review and documented approval must be completed by physical or electronic signature within seven business days of receipt of the plan to support the CP’s ability to implement these care/treatment plans.
- Initiating referrals for medically necessary specialty care, as outlined in Tufts Health Plan’s medical necessity guidelines
- Prior authorization will continue to be required for covered services as it is today. The CP will submit authorization requests directly to MassHealth for LTSS services and other community-based services requiring prior authorization. These requests will follow the same process used today.
- Working with appropriate Tufts Health Plan and/or CPs staff to maintain an updated medication list and performing medication reconciliation as part of a member’s care transitions
- The CP care coordinator will share medication information (obtained from the member during an in-person home visit scheduled within 72 hours of member discharge) with the member’s PCP
- Providing assistance to the CPs in locating or engaging with members who are deemed hard-to-reach
PCPs may choose to delegate certain responsibilities to a PCP designee. The PCP designee must be a registered nurse, medical doctor, doctor of osteopathic medicine, nurse practitioner or physician’s assistant who serves on the member’s care team and has face-to-face contact with the member’s PCP. Responsibilities that may be delegated to a PCP designee include:
- Participating on the member’s care team
- Reviewing and approving the member’s treatment plan or care plan and LTSS care plan
- Medication reconciliation follow-up
For more on the CPs Program, visit the MassHealth website.