My Care Family, also known as the Merrimack Valley Accountable Care Organization (MVACO), is a formalized partnership between Greater Lawrence Family Health Center, Lawrence General Hospital, and AllWays Health Partners. The partnership, comprised of 130 primary care providers across 16 practices, was formed to improve the care of MassHealth patients in the community.
Family Continuity is a non-profit mental health and social services agency that supports Eastern and Central Massachusetts. The organization focuses on providing individuals with community-based resources that will reduce the need for institutional care.
With a mission statement to “inspire individuals and families to achieve overall wellness through counseling, support, education, and making connections to community,” Family Continuity has worked diligently to offer a spectrum of emotional, developmental, and behavioral programs for individuals of all ages. The organization offers a mix of community and home-based services in order to best assist each patient who seeks care.
Challenge
MVACO regularly needs to send and receive care plans with their MassHealth Community Partners, including Family Continuity, an affiliated partner of Behavioral Health Partners of Metrowest. Under the MassHealth ACO program, Community Partners provide behavioral health or long term support and services to MassHealth-covered patients.
Care plans are generated by a Community Partner to assist providers in keeping their shared patients safe, healthy, and out of the hospital. A Community Partner works with their patient to complete a care plan, and the plan is then sent to MVACO for the patient’s Primary Care Physician (PCP) to review, update as needed, and sign. The PCP then sends the signed care plan back to the Community Partner.
In the past, a Community Partner would generate the care plan after seeing a patient and fax it to MVACO. MVACO would then take the care plan to the patient’s physician for signature, and send it back to the Community Partner via fax. As this process could take significant time to complete, MVACO searched for a better solution and piloted a new electronic exchange of information with Family Continuity.
Solution
MVACO worked with Family Continuity and HIway Account Managers to implement an electronic workflow that improved the process of sending and receiving the care plans. In the new workflow, a staff member at Family Continuity sends the care plan electronically via Direct Messaging over the Mass HIway to MVACO. Once the care plan is received, it is forwarded to the appropriate physician who reviews and signs it, before sending it back to Family Continuity as a PDF via another Direct Message.
Using Direct Messaging can streamline the process of receiving care plans and allow for easier tracking as staff will only need to monitor one communication method.
“The HIway will help us contain our care plans in one spot.”
– Laura Konarski, Community Partner Relationship Manager, MVACO
Implementation
The Direct Messaging connection between MVACO and Family Continuity was implemented using the HIway Webmail option. This option can be used by providers who have an EHR system that doesn’t have built-in Direct Messaging capabilities. It works based on exporting and importing patient information from the EHR and exchanging this information via the secure HIway Webmail connection.
Implementing the new workflow was a simple process for MVACO, as only one staff member’s routine was affected. Nevertheless, MVACO intends to train an additional person, which will be useful when more Community Partners begin using Direct Messaging to send their care plans. It will also ensure that if a staff member is out of the office, there will be another person on hand to facilitate the signatures from the PCP.
Support from the Mass HIway
The Mass HIway offers HIway Adoption and Utilization Support (HAUS) Services free of charge to assist organizations in the effective deployment of HIE to enhance care coordination. The The HIway Account Managers assisted MVACO and Family Continuity with the implementation of Webmail and the new workflow by facilitating calls between the two organizations to discuss workflow changes, which documents would be shared, and training the staff from each organization on how to use Webmail.
Timeline
The HIway Account Managers began working with MVACO in December 2019. Due to the COVID-19 pandemic, the expected three month implementation process took longer than anticipated. The project was completed in September 2020, when both MVACO and Family Continuity were on-boarded to HIway Webmail and began receiving and sending the care plans electronically.
Moving Forward
The workflow between MVACO and Family Continuity has largely switched to an electronic exchange. However, MVACO currently still uses the old method of faxing with other Community Partners. Many of those partners are not on the Mass HIway, nor do they use other Direct Messaging capabilities.
After the successful HIway Webmail implementation between MVACO and Family Continuity, the MVACO organization is leveraging HAUS services to help them explore the possibility of working with other Community Partners with whom they share patients. In November 2020, a HIway Account Manager reached out to four Community Partners to facilitate a conversation with MVACO around sending care plans via Direct Messaging. MVACO has started to implement electronic care plan exchange workflows with Eliot Behavioral Health Community Partner (BHCP) program, Massachusetts Care Coordination Network, Community Care Partners, and Merrimack Valley Community Partner.
These Community Partners all use the Direct Messaging capabilities of their eHana Care Management platform, which will allow for streamlined workflows between these organizations and MVACO. They will not need to use HIway Webmail for this purpose. Using the Direct Messaging services built into the EHR can simplify the on-boarding process, and eliminates the EHR information exports and imports required when using HIway Webmail.
Recommendations for Other ACOs