BILH Care Management Resources

BILHPN Care Management structure, function, and resources are being reorganized to align with the 2023 BILHPN strategic priorities. New focus areas of work include SNF utilization and SNF LOS management within MSSP ACO; Ambulatory Quality in all risk payors and contract based payor specific strategy within network wide Tufts Medicare Preferred and Cigna contracts.

BILHPN Care Management Update

BILHPN Nurse Care Managers and Social Workers are being reorganized to meet these programmatic needs, which means that we are moving away from our prior workstreams which involved Medicare MSSP patients only within a Complex Care Management program, which included elements of post discharge follow-up. Additionally, we will not have any centralized social work resources as they will be refocused within the SNF programs. Care Management’s role in addressing the strategic priority of readmission reduction will fall within the SNF programs, where the teams will be working with MSSP patients through the 30 day window for readmission penalty period.

Additionally, as a reminder, BILHPN transitioned to the Wellsense Mass Health ACO on 4/1/2023.  Care Management for Mass Health will be moving to the Wellsense programmatic teams and referrals can be sent to starting on 4/10/2023. 

BILHPN will continue to support Mass Health patients with social determinants of health needs within the scope of the flexible services program and BILHPN employed Community Health Worker’s, which will be overseen by Katherine Record. Mass Health Community Health Worker referrals can be sent to a central email

BILHPN is also working collaboratively with the office of Health Equity, Diversity, and Inclusion to develop a Community Health Navigator program to address the social determinant of health and quality care gaps within our underserved populations within our Network.