Community Care Partners

Care Coordination IS Public Health! Every day our Care Coordinators, Community Health Workers, Nurses, and Clinicians support MassHealth members with the highest needs. Our teams are boots on the ground in communities where they support our most vulnerable neighbors to address root causes of health inequities, reduce risk and acute utilization, increase access to care, navigate the healthcare landscape, and partner with members to achieve their wellness goals. Care Coordination bridges gaps public health systems seek to fill and it is integral to advancing health equity for the most complex and disadvantaged populations.

The City of Boston Access to Counsel Program is a supportive service designed to prevent evictions in eligible households with school-age children in grades K-12. Access to Counsel provides full legal representation for families at risk and can become involved at the Notice to Quit or hearing notice stage. This is impactful, as many households—especially low income families—often lack representation in housing court.

Housing is health care. Expanding access to counsel goes beyond connecting to legal resources. It represents a critical safeguard against the consequences on health and wellbeing that can arise from housing instability.

The Access to Counsel program can help to:
🏠 Reduce eviction risk, prevent homelessness, and preserve existing housing
⚖ Increase advocacy and counter legal representation disparities
👶🏾 Support children’s well-being, development, and school attendance
👩‍👧‍👦 Preserve safe living conditions and family unity


For more information, please visit: https://www.boston.gov/departments/housing/access-counsel-program

Access to primary care is becoming increasingly fragile. From the perspective of Community Care Partners (CCP) and our fellow Massachusetts Community Partners, this is not abstract—it is what we see downstream every day.

When primary care access collapses, people do not disappear. They surface in emergency departments, inpatient units, and behavioral health crises—not because those settings are appropriate for routine care, but because they are often the only access left.

Our care coordination teams support members who:
• cannot establish primary care for months
• have lost long-standing physicians to burnout or early retirement
• rely on emergency departments for medication refills and chronic disease management

We also know that many of the members we serve—when properly supported in primary care—require more time in appointments, experience difficulty with timeliness, and face significant health-related social needs that affect access, engagement, and continuity of care. These realities are not barriers of motivation; they are reflections of complexity.

As primary care capacity erodes, system-wide stress increases. Expectations often shift—implicitly—onto care coordination teams to resolve gaps that no longer have providers, appointments, or treatment pathways behind them.

Care coordination, community health workers, nurses, social workers, and interdisciplinary teams—across CCP and our fellow Community Partners—work every day to stabilize care, build trust, and support member engagement. But these roles cannot replace primary care, especially when part of the purpose of our program is to connect vulnerable persons to primary care. We can only mitigate the impact of primary care absence for so long.

From a population health lens, the communities hit first and hardest are those already facing the greatest barriers: rural populations; publicly insured and low-income individuals; people living with chronic illness, disability, or serious mental illness; and immigrant communities. In Massachusetts, these are the very members served by Community Partner programs.

Workforce expansion and training pipelines matter. But without addressing the underlying causes, the system risks accelerating churn rather than building stability.

Care coordination can stabilize gaps—but it cannot replace primary care.

The MIRA: Massachusetts Immigrant and Refugee Advocacy Coalition, Inc. (MIRA) has launched an exciting new program to provide full legal representation in Immigration Court for income eligible immigrants. The Massachusetts Access to Counsel Initiative, or MACI, offers a centralized intake and referral system for individuals facing Immigration Court proceedings.

Detained and non-detained individuals from Massachusetts in need of legal assistance can now call the MACI Intake Line at (508) 505-4588. Individuals that call will complete a 15-30 minute intake process. Eligible individuals will be referred to a contracted legal partner for a consultation (pending capacity). Representation is FREE under this program.

The hotline has access to a language line to assist individuals with limited English proficiency.

🧡 Communicating What Can’t Always Be Counted

At Community Care Partners, we work every day to bridge two worlds: the person and the payor system. We pursue creative ways to optimize care that honors both — but some of the most meaningful parts of our work are also the hardest to quantify.

Trust. Relationships. The moments where someone feels heard, respected, and connected again. These are the foundations of health equity — yet they don’t always show up neatly in utilization, cost, or outcomes reports.

That’s why we’re seeking input: what’s the best way to communicate this kind of care — the qualitative, human-centered work — alongside the metrics that systems require?

We believe both matter. And we believe the future of community care depends on finding ways to show the value of both.