Addressing social and behavioral health through fully integrated, interdisciplinary care teams
Care management & redesign Behavioral health & addiction SDOH & health equity Workforce development
Commonwealth Care Alliance (CCA) community health workers (CHWs) are embedded in the communities where CCA members live and are key to CCA’s ability to address member needs. They have a deep understanding of community resources, maintain relationships with diverse partners, build trust with members, and open the lines of communication for our behavioral health and medical staff.
Jorie Epstein-Mares, Melanie Fried, and Saki Moon discussed CCA’s social and behavioral health programming for members dually enrolled in Medicare and Medicaid. Their presentation, from the perspectives of CHWs and behavioral health clinicians, focused on the enhanced interdisciplinary team collaboration and integration to meet the complex medical, behavioral, and social needs of their members including the team’s resource specialist role, housing program, addressing food insecurity, and doula support for pregnant members and new parents.
- Jorie Epstein-Mares, LICSW, C-SWHC Community Health Worker Program Clinical Director, Commonwealth Care Alliance
- Melanie Fried, LICSW Director, Behavioral Health Clinical Care Director, Commonwealth Care Alliance
- Saki Moon, Community Health Outreach Worker, Commonwealth Care Alliance