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. The two areas of assistance currently available through the MGH ACO Health Related Social Needs program (HSRN - formerly "Flexible Services") are Nutrition supplemental services and Housing supplemental services.

Sections

• Identifying MGB ACO patients
• Eligibility for HRSN
• Nutrition supplemental services
• Housing supplemental services
• To Refer

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  

• Eligibility
  • Nutrition eligibility test "very low food security" survey

   

• Services

Housing Advocacy

• Eligibility
  • Advocacy tip: housing services eligibility is strict. Must be homeless, and must have an eviction record (recent or remote). May be best for those 55 and older who are homeless and don't already have a housing advocate - they can provide assistance with housing search.
  • HUD Category 1 definition of Homeless: lacks a fixed, regular, and adequate nighttime residence, meaning:
    1. Has a primary nighttime residence that is a public or private place not meant for human habitation; or
    2. Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs); or
    3. Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution.


• Services

To Refer

• Find and pin Epic referral form
• The referral form
• Referral Tips:
  • If you have someone whom you think qualifies you can either enroll them and wait for a response from MGB or email Kristen Risley and ask her to verify.  Also email her if you have a kiddo who doesn’t qualify and you’d like us to investigate if someone in the family does.  Alternately, you can tell the family to ask their PCP’s office though this will add a substantial amount of time to the referral process and thus the family getting served.
  • Kristen recommends if you have someone you are unsure qualifies for housing help, to enroll and let MGB help you.  In general, be sure to set expectations for your clients that there is a program they might qualify for and you need to check eligibility before you can tell them they are enrolled and will get served by this program.