Community Partners Program

For Tufts Health Together

MassHealth identifies members of Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) who are eligible for referral to the Community Partners (CPs) Program, in which community-based entities provide care management and coordination.

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. Long-term services and supports (LTSS) community partners 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 CPs throughout the state to service MassHealth members from all MA communities. Our Tufts Health Plan care managers work closely with CPs to ensure members working with them have the necessary support.

As part of this program, a comprehensive assessment of needs is conducted and a member-centered treatment plan is developed.  

What is the member's PCP's role with the CP?

As part of this 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 BH treatment plan and/or LTSS care plan
    • 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

PCP Designees

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.