At Eliot, our Care Coordination Division is committed to delivering impactful, person-centered care through our Behavioral Health Community Partner (BH CP) and Health Home programs. This dedication is reflected in the outcomes we’ve achieved, the feedback we’ve received, and the lives we’ve helped transform.
Behavioral Health Community Partner (BH CP) Program Success
With enrollment projected to exceed 4,000 members, our BH CP program has consistently surpassed expectations in addressing Social Determinants of Health (SDoH). Key highlights include:
- HRSN Screenings: Over 70% of completed Health Related Social Needs (HRSN) screenings identify critical needs such as housing, food, and social isolation.
- Support Services: Our team connects members with community resources and provides direct support, including distributing Mobile Food Market Bags.
- Care Plan Excellence: Care Managers complete Person-Centered Care Plans on average within 130 days—22 days faster than state benchmarks and outperforming other programs statewide.
Member Impact
The gratitude expressed by members underscores the life-changing impact of our work. One member shared:
“My BH CP Care Manager has been a God-send to me. She has advocated on my behalf on so many things I don’t know where to start. I would never have been able to navigate these waters without her advocacy. I would have been out on the streets and probably deceased by now without her.”
Collaboration and Service Integration
In a recent visit to Eliot CHS in Lexington, MassHealth leaders and state agency representatives explored the success of our BH CP program. Eliot leadership highlighted our service integration model, which coordinates care across ACCS, CBHC, and Homeless Services, demonstrating the value of holistic, connected support systems.
Health Home Program: Achieving High Standards
Eliot’s Health Home program, part of the One Care initiative, continues to achieve exceptional results with a consistent 20% annual growth rate. Recent performance highlights include:
- Transitions of Care (TOC): 65% of member visits occurred within 48 hours of TOC, exceeding the 60% benchmark.
- AOD Treatment Initiation: 82% of new AOD diagnoses led to treatment within 14 days, surpassing the 43% benchmark.
- Annual Assessments and Care Plans: 95% of annual assessments and care plans were completed by their due date, far exceeding the 80% and 90% benchmarks.
Member Success Story
One member faced significant challenges due to cultural barriers, making it difficult to trust and engage with providers. With consistent support from their Health Home Care Partner, this member:
- Built positive, meaningful relationships with providers.
- Switched to a coordinated care network for better communication and treatment.
- Advocated for ongoing behavioral health treatment and outpatient services.
This member expressed immense gratitude, sharing that they feel validated, supported, and hopeful for the future. Their care partner described the experience as profoundly rewarding, saying, “I truly feel I’ve made a difference in their life.”
Moving Forward Together
Eliot’s Care Coordination Division is proud of these achievements and remains dedicated to providing innovative, compassionate care that improves lives. Through collaboration, excellence, and a deep commitment to addressing the needs of our members, we are shaping a brighter future for the communities we serve. Stay tuned for more updates as we continue to make strides in delivering exceptional care.