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Staff Access
Basic Needs
Basic Needs
MGB ACO Health-Related Social Needs (HRSN)
(Formerly the Flexible Services Program)
Background
The MassHealth Accountable Care Organization (ACO) program is a special MassHealth (Medicaid) program that allows funds to be used flexibly and, unlike traditional fee-for-service coverage models, includes provider incentives to address preventative care and the social determinants of health.
Sections
How do I know if my patient is a member of the MGB ACO?
Check Epic for insurance status:
See the SS Staff Meeting presentation (9/22)
HRSN Eligibility:
- Must be a member of the Mass General Brigham ACO
- Receives primary care at MGH (MGH PCP)
- Have NO insurance other the MGB ACO (including Medicare)
- Homeless or at risk for homlessness OR at nutritional risk AND meet health based criteria
- Must have one of the following Health Needs Based Criteria:
- Need assistance with one or more ADL or IADL
- Repeated ED use- 4 or more ED visits in 1 year OR 2 or more ED visits in 6 months
- AND at least one:
- High risk pregnancy - with diagnosis of preeclampsia, gestational diabetes, ar referral to Maternal Fetal Medicine
- Complex physical health need
- Behavioral health need
- If patient doesn't strictly meet definition, but you think is high risk, they will try accommodate where possible looking at constelation of qualifications.
- See referral form for more detailed criteria
Food and Nutrition Programs
- NOTE this section is in the process of being updated.
- Fresh Connect Debit Card Program
- Allows individuals the ability to purchase the fresh produce they want
- Only valid at certain locations
- $120/week benefit
- This program can take 2-2 1/2 weeks to begin and lasts for six months
- Serves as a supplement to SNAP and does not affect SNAP benefits
- Fresh Food Generation - provides weekly box of fresh produce and grains to be prepared at home
- Community Servings
- For highest risk patients (diabetes, substance use, etc.) provides medically tailored home-delivered meals delivered weekly
- Applying through the ACO allows eligible individuals to bypass he waitlist and to receive services for a specified time (up to 6 months)
- Note: those approved through the traditional Community Servings referral, may be subject to a waitlist, but can receive services without that time limit
- Includes two nutrition counseling sessions
Housing Advocacy
If found eligible, a case manager will be assigned to your patient from a local housing agency. The housing agency will be assigned based on location and a triage system - the 2024 housing agencies are Metro Housing Boston, Housing Families and Vinfen. The case manager does an assessment and will let the patient know the extent that they are able to help with the need.
Services Range from:
- Help filling out applications
- Connecting patients with realtors
- Helping with first, last, and security
- Legal help through GLBS where appropriate
- Education and support
Note that this program runs a waitlist. The referral form includes information to help determine urgency. In January 2024 were processing referrals from July 2023; though hoping with addition of new vendor that future waitlists may be reduced.
HSRN housing assistance can also offer additional services for those with asthma and with small housing modifications.
For housing modifications overall, services include:
- Installation of grab bars and hand showers
- Doorway modifications
- In-home risk environmental risk assessments
- Remediation of mold
- Refrigerators for medicine such as insulin
- Pest management supplies and services
- Air conditioner units
- Traction or non-skid strips
- Night lights
- Training to use such supplies and modifications
More specifically for asthma, services include
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Air purifiers
- Vacuums with HEPA filters,
- Bed covers and hypoallergenic pillow cases.
To Refer
For more information or to refer: https://redcap.partners.org/redcap/surveys/?s=JAHKAMMT878NDMJX
To refer to both nutrition services and housing advocacy - submit two separate referrals.
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