Business Analysis and Program Support for Joint ACO, MCO and CP Roles, Responsibilities and Processes Facilitation and Implementation

Client Description

The client is a leading Northeast managed care organization (MCO) with a Medicaid Managed Care program serving over 300,000 Medicaid members.

Challenge

The organization was awarded one of the Commonwealth’s Accountable Care Organization and Managed Care Organization (ACO/MCO) Community Partner contracts required through MAHealth Reform, and needed to develop and implement the innovative three-way partnership for Community based care coordination within a short time-period.  This MCO’s contract includes multiple Statewide ACO partners and significant number of Long Term Services and Supports (LTSS) and Behavioral Health (BH) Community Partners (CPs). Implementation had to address new contractual understandings, documented processes, new clinical policies and procedures, workflows, new system configuration processes, and importantly facilitation to support the Community Partners understanding of its new relationships, roles, responsibilities and processes to integrate the care management and care coordination activities with the ACO providers and the MCO.

Ninestone Approach

Ninestone brings deep capability for new program analysis, planning, education, and internal and external party documentation development and dissemination to assist the Integrated Care Management Department in both its operational responsibilities and facilitating portions of this new three-way partnership implementation.  The initial solution included planning and participation in the MCO initiated ACO and CP Joint Meetings where the data exchange and care management and coordination change and transition of roles, responsibilities and processes were described, discussed and documented. Ongoing assignments include quarterly meeting facilitation, outreach and care management workflow, training updates, job descriptions and documentation support, including hard to reach member initiatives and MCO and CP role clarification for transitions of care and complex care management.

Technology

The Integrated Care Management Department’s responsibility included identification of the most efficient and effective method of exchanging CP member eligibility assignment and referral data and information with ACOs and CPs, maintaining respect to individual CP EHR and care management systems. Further, the MCO needed to develop an analytic solution to gather each eligible member’s relevant claims and utilization information to accompany the CP assignment monthly updates, and ad hoc CP requests.

Results

Ninestone has been maintaining the required timelines, delivering required documentation, participating in the organization of the Joint Meetings agenda priorities and program operationalizing as well as documentation review and updates of processes.  The organization continues to effectively support the program as implementation continues through to 2019.