Integrated, cross-organizational care teams can offer high-quality care for people with complex health and social needs ā€” individuals who often encounter fragmented health and social service systems. This interdisciplinary approach places individuals at the center of their care, ensuring coordination across multiple providers, health systems, and community-based organizations. Building relationships, establishing clear communications, and clarifying shared care planning processes is critical to making these models work.

This brief outlines lessons from the Center for Health Care Strategiesā€™ MassHealth Care Planning Learning Collaborative, where Massachusetts Accountable Care Organizations and Community Partners integrated care planning across their organizations to improve care for Medicaid members with complex needs. The brief is made possible by the Commonwealth of Massachusetts Executive Office of Health and Human Services and Abt Associates.

While focused on the Massachusetts context, the brief can inform providers, payers, and community partners in other states seeking to improve care for people with complex health and social needs.