Integrated and inter-organizational care teams — including physicians, nurse practitioners, physician assistants, nurses, social workers, care coordinators, care managers, and community health workers — offer a valuable solution to provide high-quality care for people with complex health and social needs. In 2017, Massachusetts’ Medicaid program, MassHealth, used a federal 1115 waiver to restructure its delivery system to support integrated and inter-organizational care teams. These care teams, which include staff from accountable care organizations (ACOs), managed care organizations, primary care practices, and community partners, engage in shared care planning to improve care for eligible MassHealth members.

In this webinar, made possible by MassHealth and Abt Associates, the Center for Health Care Strategies (CHCS) shared lessons from the MassHealth Care Planning Learning Collaborative on building key partnerships to support integrated teams. Leadership from MassHealth provided insights on its restructured managed care program and the value of state investment in shared care planning. A panel discussion including clinical staff from an ACO, primary care practice, and a behavioral health community partner reviewed the solutions they developed to deploy effective integrated teams. They discussed best practices in shared care planning, the key elements needed for effective inter-organizational care teams, and other strategies pursued by participants of the learning collaborative.

YouTube video


I. Best Practices for Integrated and Inter-Organizational Care Teams: Lessons from the MassHealth Care Planning Learning Collaborative

Speaker: Karla Silverman, MS, RN, CNM, Associate Director, Complex Care Delivery, CHCS

K. Silverman welcomed participants, reviewed webinar goals, and presented key lessons from MassHealth’s efforts to support integrated and inter-organizational care teams. She shared innovative solutions created by MassHealth learning collaborative participants to improve shared care planning processes and strengthen cross-organizational partnerships.

II. Panel Discussion: Ground-Level Perspectives on Partnering to Improve Shared Care Planning   

Moderator: K. Silverman, CHCS

Panelists: Gary Sing, PhD, Director of Delivery System Investment and Social Services Integration, MassHealth; Christine Rooney, MD, Chief Medical Officer, Merrimack Valley ACO; Leah Kean, LICSW, Behavioral Health Community Partner Director, Eliot Community Human Services; Jennifer Sciacca, MSSA, LCSW, LTSS Program Manager, BMC HealthNet Plan / Well Sense Health Plan

The panel kicked-off with a brief interview with Gary Sing about Massachusetts’ investment in improving shared care planning between ACO and Community Partners. Panelists then shared insights about the value of participating in the learning collaborative to build and strengthen partnerships. They shared innovative solutions to common challenges, focusing on the tools and processes ACOs and community partners need to support effective care coordination for MassHealth’s complex members.

III. Moderated Q&A 

Moderator: K. Silverman, CHCS