CCP and LTSS Care Partners is a collaboration of six long standing, community-based organizations serving Eastern Massachusetts — Bay Cove, Boston Senior Home Care, Justice Resource Institute, Mystic Valley Elder Services, Somerville Cambridge Elder Services, and Vinfen. The specialization of each Affiliated Partner strengthens the collaboration as we aim to meet our collective goal. Our multidisciplinary care teams are comprised of Licensed Social Workers, Community Health Workers, Registered Nurses (RNs), and Recovery Coaches and provide care coordination services to approximately 5,000 MassHealth members in the Boston, North, and Southeast regions of the commonwealth. Our overarching goal is to make it easier for individuals and families we serve to access a continuum of quality care across the health care and social services systems in the state.
Support/Services We Offer
Our multidisciplinary care teams work with members to strengthen linkages and connections with health care providers and community-based organizations as they strive to meet their desired health and wellness goals. Where there is a barrier, our care coordinators work to problem solve, promote access, and coordinate services and care in an effort to ensure no need goes unmet. Our care coordinators offer flexibility when connecting with members to support their social and health care needs—on the phone, in their home, at a doctor’s office, or at another convenient location in their community. We offer a variety of support, as tailored to each member:
- Assist with scheduling and keeping medical appointments
- Assist with obtaining transportation services (The Ride, Disability T-pass, MassHealth transportation)
- Assist with getting medications
- Connect with medical providers
- Reach wellness goals (recovery, smoking cessation, diabetes management)
- Attend appointments with members as indicated
- Assist with getting medical supplies (cane, walker, wheelchair, diabetes test strips)
- Connect to housing agencies and supports
- Assist with applications for financial assistance (Food Stamps, Social Security, Cash Assistance)
- Connect to community resources (social clubs, YMCA, libraries, free events)
- Coordinate referrals for in home support (Visiting nurse, Personal Care Attendant)
What Is a Community Partner?
A Community Partner, whether a stand alone organization or a consortium of several organizations, is a MassHealth funded care coordination program serving individuals and families with MassHealth only. The program, launched in 2018, serves to break down barriers and make it easier for MassHealth members to get access to the care they need, inclusive of basic necessities such as support with housing, employment, food security, and transportation. Community Partners employ multidisciplinary care teams that in turn partner with any number and type of provider to promote integrated care across the health care system and social services programs. And Community Partners often collaborate with an member’s ACO/MCO plan to further enhance access to quality, integrated care. Complex members with high health care utilization rates and co-morbidities can benefit from one of two types of Community Partners:
Behavioral Health Community Partner
Behavioral Health Community Partners, or BH CPs, provide care management and coordination across the health care continuum for members with significant BH needs. BH CPs coordinate a members’ physical health and behavioral health care as well as their LTSS and social services. There are 18 BH CPs across the Commonwealth. Collectively, BH CPs can support up to approximately 45,000-50,000 members at any one time.
Long Term Services and Supports Community Partner
Long Term Services and Supports Community Partner, or LTSS CP, provide LTSS care coordination for MassHealth members with complex LTSS needs. They partner closely with an members’ ACO/MCO plan, serving as the LTSS subject matter expertise on the Care Team. There are 9 LTSS CPs across the Commonwealth. Collectively, LTSS CPs can support approximately 15,000-20,000 members at any one time.