Learn the strategies required to deliver patient-centric, quality care for individuals with complex care needs. Successful coordination and management requires networking with multiple care providers and linking each intervention to the individual’s overall care.

Even with health insurance gains, access may still be an issue. State Innovation Waivers offer an opportunity to build on the Affordable Care Act and increase health insurance affordability. States can ask the federal government for authority to change parts of the ACA to achieve their goals.

The Care Transformation Collaborative of Rhode Island (CTC), a patient-centered medical home initiative managed by UMass Medical School, explains how primary care practices can build a medical neighborhood by creating a community health team to provide behavioral health and social support services to patients with high-cost, complex care needs.

Many individuals with disabilities are interested in working, but don’t know how doing so will affect their ability to receive public benefits like Social Security and Medicare. Work Without Limits was established in 2000 to provide Massachusetts residents who receive public benefits with information to help them make informed decisions about going to work.

Our customized, results-oriented high-risk medication program dramatically reduced refills for this Medicare Part D client with targeted prescriber outreach. This indicates discontinuation of the prescription or change to a safer medication.

More than 150 adults with acquired brain injury in Massachusetts transitioned from long-term care settings to the community from November 2010 to August 2013. Some individuals transitioned with an increase in risk incidents. A registered nurse care manager was engaged to address the needs of those at high risk. The results show there was a decrease in hospitalizations and emergency room visits.

An assessesment of the impact of the MassHealth, the Massachusetts Medicaid program, Children's Behavioral Health Initiative implemented in 2007. The initiative, requires behavioral health screening at well-child appointments, substantially increased the percentage of children receiving behavioral health screenings.

Integration strategies and coordination benchmarks within the Massachusetts Medicaid Management Information System (MMMIS) are used to ensure accurate Medicaid and Medicare enrollment; fully engage service delivery options (including managed care and integrated care programs); and effectively cost-avoid, reprice, or cost-share to ensure the state’s lowest payment liability.

This report describes the process of providing integrated care for patients with substance use disorders at three sites in central Massachusetts: Edward M. Kennedy Community Health Center, Family Health Center of Worcester, and Community Healthlink. It identifies common practices that improve care coordination and presents key findings.