Community Partner Program

As part of the Healthcare Reform Initiative officially launched by the state of Massachusetts on March 1, 2018, MassHealth has certified large Hospital Systems and Health Plans statewide as Medicaid ACO/MCO Plans. These new plans are now administering Health Coverage to MassHealth members on behalf of MassHealth. This means they’re responsible for the total cost of care, authorization of services and provision of medical services for MassHealth members.

On July 1, as part of these reforms, MassHealth launched a new specialized care coordination program known as the Community Partner Program. This program has been specifically designed to support the highest utilizers of MassHealth services across the state, as they attempt to navigate the complex healthcare system here in Massachusetts. MassHealth has certified two types of Community Partners (CPs) - Behavioral Health (BH) CPs and Long-Term Services and Supports (LTSS) CPs - who will, in turn, partner with the new Medicaid ACO Plans to provide integrated care to members. Bay Cove has been certified as both a BH and LTSS CP.


As the Lead or Primary Care Coordinator for members enrolled within our CP programs, we are responsible for providing Health Home Services including: Outreach and Engagement, Assessment and Care Planning, Care Coordination, Transitional Care and Med Reconciliation, Health and Wellness Promotion, and Referrals to Social and Community Supports.  

Bay Cove operates five new CP Care Teams in the Greater Boston area, as well as in the Southeast area (Brockton, Taunton, Fall River, and New Bedford). Each Care Team has a Team Leader and approximately nine Care Coordinators of varying disciplines, including LICSWs, LSCWs, RNs, Recovery Support Navigators and Community Health Workers.

Care Coordinators outreach to enrollees as much or as little as needed, though are required to have at least one outreach per month, to either the enrollee or a member of the enrollee’s expanded care team.

Benefits of a Community Partner (CP) Program

  • Care Coordinators will partner with Enrollees and all of the Enrollees’ existing Providers: Primary Care Providers, Medical Specialists, Behavioral Health, Community-Based Service Providers, and Home-Based service providers such as Visiting Nurses and Home Health Aides.

  • Care Coordinators will aim to integrate all existing services on behalf of the Enrollee and ensure that the Enrollee has access to any new services needed.

  • Care Coordinators will support the Enrollee in addressing any barriers to getting treatment, with the goal of improving the Enrollee’s overall health/wellness.

  • Care Coordinators will complement the existing services, promote communication amongst all providers and aim to integrate care in a collaborative way.


  • Must have MassHealth only;

  • Be between the ages of 21-64;

  • Meet certain diagnostic criteria

Learn More / Contact Info

Contact: Eleanor Zambrano
Phone: 617- 533-9166

For more information about the CP programs, please visit