Partners HealthCare Choice, our Medicaid Accountable Care Organization (ACO), is dedicated to improving access to quality health care for high-risk MassHealth patients by meeting them “where they are” in the community. At times these patients need an extra hand to help them manage their health—so a program with other ACOs in the state, along with MassHealth, is working to provide that helping hand.

The aim of the Community Partners (CPs) Program is to connect Medicaid patients with appropriate services and support that augment their existing care plans. The CPs themselves are community-based organizations that work with ACOs to manage care coordination—categorized as either Behavioral Health CPs, for serious mental illness and substance-use disorders, or Long-Term Services and Supports (LTSS) CPs, for complex physical and developmental conditions or disabilities.

Now, when Partners receives a list of identified patients from the state, those patients are assigned to the appropriate CP based on their conditions and locations. The CPs focus on enhancing areas such as emotional management, interpersonal skills, and self-advocacy, while coordinating with the patients’ care teams so they are aligned on needs.

“The Community Partners program can empower primary care physicians to better focus on providing care centered on the whole patient while simultaneously reducing administrative burden,” says Salina Bakshi, MD, Clinical Lead for the Community Partners Program at Partners HealthCare. “The deep relationships that the CPs have with their community provide a unique opportunity for the health care system to improve delivery of high quality, integrated medical and behavioral health care.”

Read more on the integrated support system provided by CPs—and how they’ve helped one local patient—here.