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Name of Program| Commonweath Care Alliance (CCA)

When established| 2019

Enrollment Milestones|Available to all CCA members presenting to partner hospitals & ERs (CCA serves >40,000 members across Massachusetts). Began at Boston Medical Center in 2019. Expanded to Baystate Medical Center and North Shore Medical Center (Salem Hospital) in 2020, and Beth Israel Deaconess Medical Center in 2021.

Core services| Creating pathways to manage patients at home and directing acute care treatment in the community. Multidisciplinary team includes Physicians, RN, Community Health Workers, Behavioral Health specialists, and Community Paramedics. We take a consultative role with ER and hospital partners. Home treatment is primarily carried out via our Community Paramedicine partner, with Virtual Medical Control physician. We collaborate closely with longitudinal clinical and care management teams and focus both on acute medical needs as well as psycho-social elements that often drive hospitalizations.

Population served| CCA members, who are dually-eligible (Medicare & Medicaid) with high levels of medical comorbidities plus behavioral, social, and functional needs.

Area served| Boston (& North Shore) plus Springfield, MA metro areas (in particular, the catchment area of our 4 hospital partners).

Outcomes or successes| 2021 CCA internal statistical study showed a ~6% decrease in hospital observation stays at partner hospitals, with estimated annual savings of ~$1M and ~$1.86-to-$1 return on investment. Strong collaborative relationships with hospital partners. Anecdotally excellent patient experience. Ongoing data monitoring including clinical outcomes, patient & provider experience, and financial performance.

Unique feature| Highly complex dual-eligible population with high levels of SDOH needs and behavioral health complexity; multiple geographic sites; physically based in hospitals but not affiliated with hospital (partnership model); payer-provider organization; collaboration with community paramedicine as well as longitudinal clinical and care management teams; embedded CHW’s and BH clinician; current and future integration with other clinical innovations (Crisis Stabilization Unit, engagement center).

Leadership| Vijay Kotecha, MD (medical director); Lauren Easton (VP); Haile Hernandez (CHW manager)

Contact information|


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