Population Health

Alert: Most CHA centers and services will be closed during the Martin Luther King Jr. holiday. Please see this schedule for details.

What is Population Health?

At CHA, we have changed the way we care for large groups of patients. Instead of episodic care when people are sick, we want people to stay healthy at all times.
We are doing this using population health - providing targeted outreach, health care services and related support to groups of patients, based on their specific illness or needs.

What is an ACO?

An Accountable Care Organization (ACO) is a group of healthcare providers (primary care teams, specialists, hospitals and a health plan) who work together to give patients all the services they need while striving to meet certain goals:

  • Improving the patient experience (higher satisfaction, improved access)
  • Improving outcomes for all patients (improved quality)
  • Reducing the costs of healthcare

Why is this important?

CHA is part of a national effort to improve healthcare for all patients, following the Three Part Aim.

How does this affect you?

CHA works with a selected network of doctors and hospitals to provide coordinated care and ensure high quality services. As a result, your CHA provider may recommend a particular doctor based on your health needs, but it is always your choice about what doctors you see or hospitals you visit.

If you choose, you can ask us to not share your personal health information with any other ACO in which any of your doctors or other healthcare providers participate.

How is CHA working to improve health care?

There are many new initiatives to help patients stay healthier. These include:

  • Patient-Centered Medical Homes: Medical homes are a new way to provide you with health care. Medical homes organize care around patients by working in teams, coordinating services, and tracking results over time. The “team” is led by your CHA doctor and may include nurses, medical assistants, front desk staff, counselors, pharmacists, health educators, and more. CHA’s PCMH practices are recognized by the National Committee for Quality Assurance (NCQA).
  • Care Management: These staff help our sickest patients navigate the health care system and coordinate all the care they need. This means that patients who are most in need have more support to stay healthy or feel better.
  • Planned Care: CHA’s planned care team help patients with significant health needs who are at risk for getting sicker, without good supports. Planned care coordinators also address gaps in care and community support needs for all CHA’s patients.
  • Integrated Case Management: Each CHA hospital has case management staff to help facilitate patient transitions to home or other points of care. We have now integrated case management staff across CHA’s inpatient and outpatient settings to facilitate better transitions, help us better understand our patients, and improve communications.
  • Hospital to Home Program: This program works with patients and families to make sure patients get the care and support they need once they leave the hospital. It includes sending patients to a clinically appropriate setting after discharge, following patients to that setting, and providing community supports, as needed (like Visiting Nurses).
  • Behavioral Health Integration: CHA is working to bring together its behavioral health and primary care services in the same locations to give more support to patients with behavioral health needs. This is particularly important for patients with behavioral conditions that prevent them from effectively managing their health needs.
  • Electronic Health Record: CHA is recognized for having an exceptional electronic health record, Epic, that lets us share data securely across our system. So if you see a primary care doctor in Somerville, go to the Emergency Room at Cambridge Hospital, and see a specialist at Whidden Hospital, all your providers will understand your health needs. This will help reduce unnecessary tests and treatments and give you more timely and coordinated care.
  • MyCHArt: This electronic portal lets you stay more connected to your care. For example, it will let you send a secure message to your health providers and review your medical records online – making it easy to be a member of your health care team.
  • Strategic Relationships: CHA is proud to partner with Beth Israel Deaconess Medical Center (BIDMC) and other local facilities to provide patients with convenient, high quality, and seamless healthcare services, both in and out of the hospital.

About the MassHealth ACO

Certification from the Health Policy Commission

In 2017, CHA was certified as an Accountable Care Organization by the Massachusetts Health Policy Commission (HPC). The HPC's first round of ACO Certification includes 17 HPC-certified ACOs and is a significant milestone for Massachusetts, making it the first state to implement state-wide, all-payer standards for care delivery. Learn more

Tufts Health Together with CHA

Tufts Health Plan and Cambridge Health Alliance (CHA) have partnered to create Tufts Health Together with CHA a new MassHealth plan. Learn more

More about CHA's Population Health Efforts

Name and Location

Cambridge Public Health Commission D/B/A Cambridge Health Alliance
1493 Cambridge Street
Cambridge, MA 02139

Primary Contact

Lisa M. Trumble
Senior Vice President of Accountable Care Performance
Email: lmtrumble@challiance.org
Phone: 781-397-6504

Composition of ACO

Cambridge Public Health Commission D/B/A Cambridge Health Alliance is the sole participant in the Cambridge Health Alliance Accountable Care Organization.

ACO Participants

CHA includes CHA Cambridge, CHA Somerville and CHA Everett Hospital, the Cambridge Health Alliance Physicians Organization, and associated care centers.

  • CHA is one of 17 health care organizations to meet the certification requirements of the Massachusetts Health Policy Commission Accountable Care Organization (ACO) program.

    Read the press release