Powering Massachusetts ACOs’ HRSN Service Delivery
As the Massachusetts state department of health, MassHealth’s 1115 Medicaid Waiver unlocked $150 million to address health-related social needs (HRSN)—funding essential food and housing services for eligible Medicaid members. For accountable care organizations (ACOs), hospitals, and payers, this presented a significant opportunity, but also a complex operational challenge: how to efficiently identify eligible members, coordinate a diverse network of services, ensure providers were paid, and demonstrate measurable impact.
Findhelp played a critical role in MassHealth’s Flexible Services program, supporting ACOs with seamless referrals, provider payments, and service tracking.
In this post, you’ll learn how:
Participating ACOs used the Findhelp platform to identify eligible members, manage referrals, and track outcomes.
Studies confirmed that addressing HRSN led to fewer hospital and ED visits and better health.
Findhelp is adapting to support new billing and compliance rules for the program’s next phase.
Proactive intervention to lower total cost of care
Findhelp functionality was instrumental for ACOs to meet Flexible Services requirements. Through our platform, ACOs sent contracted social service organizations (SSOs) reimbursable “orders” and SSOs shared back detailed outcomes.
- Automated Member Identification – Accelerated program enrollment by helping ACOs quickly find and confirm eligibility for Medicaid members.
- Streamlined Social Care Referrals – Improved member access to care by connecting them to trusted SSOs with ease.
- Payment & Compliance Support – Simplified financial operations and ensured adherence through accurate provider reimbursement and regulatory alignment.
- Data & Reporting Capabilities – Provided real-time insights to track program effectiveness and cost savings.
Findhelp’s efficient and collaborative Flexible Services workflow
1
Care Managers & Community Health Workers (CHWs)
Screen patients to determine eligibility for Flexible Services and make referrals to SSOs.
2
Social Service Organizations (SSOs)
Receive referrals, provide services, share updates, and invoice ACOs
3
Accountable Care Organizations (ACOs)
Pay SSOs for services and report outcomes to MassHealth.
- ACO care managers and CHWs accessed one platform for all social care-related referrals, on behalf of both Flexible Services participants and their general patient population
- SSOs recorded detailed referral outcomes (e.g., how many and types of meals provided) and shared this information with the ACOs, directly via the platform
- ACOs accessed real-time reporting dashboards to monitor service utilization across multiple Flexible Services programs and share required data to the State, at both individual and population levels.
- SSOs used a free reporting suite to track services provided and to invoice the ACO.
Impactful results, backed by research
The data speaks for itself—two reports from different evaluators both showed significant results for healthcare savings and improved health.
University of Massachusetts: Significant reductions
An April 2025 study by the University of Massachusetts and MassHealth (published in HealthAffairs.org) analyzed 20,000 MassHealth Medicaid members who received nutrition-related CBO services via Flexible Services.
The study showed “significant reductions in hospitalization and emergency department visits“.
$2,502
total cost of care savings
23%
reduction in hospitalizations
13%
reduction in ED visits
United States Dept. of Agriculture (USDA): Significantly improved health
Similarly, a 2023 evaluation by the USDA and Project Bread of 491 individuals showed that participation in the Flexible Services pilot program significantly improved their diet and health:
25%
became food secure
3.5
more fruit and vegetable servings consumed weekly
12.4%
increase in SNAP enrollment
99%
of participants reported improved health
Customer stories: Successfully addressing Medicaid member needs
These studies underscore the significant positive impact that addressing HRSNs through programs like Flexible Services can have on member health and healthcare utilization. However, to translate this potential into tangible results for their specific member populations, ACOs require robust tools and streamlined workflows. This is where Findhelp becomes essential, providing the infrastructure to efficiently connect members to these vital services, track outcomes, and manage the complexities of such initiatives. Leading Massachusetts ACOs have leveraged Findhelp to do just that:
Mass General Brigham
A Findhelp customer since 2019, Mass General Brigham (MGB), a nonprofit integrated health system, used their Findhelp platform to send Flexible Services referrals to 17 contracted housing and nutrition SSO partners across the state.
- MGB focused on supporting pediatric members with complex care needs and high-risk behavioral health members.
- In support of the demonstration, MGB created an HRSN Central Team who triaged patients with positive screenings and referred them to the appropriate SSO.
- Findhelp served as the central hub to navigate all stakeholders through the referral process.
MGB’s results over the course of the demonstration pilot:
5,000+
members were referred to SSO partners
40%
of pediatric members were connected to services
74%
“Got Help” rate for nutrition-related Flexible Services referrals
Community Care Cooperative
Community Care Cooperative (C3), an FQHC-led ACO, partnered with more than 20 social services organizations across Massachusetts to provide services for members with complex health needs.
- C3 used Findhelp as a pathway for care coordinators to make Flexible Services referrals for nutrition and housing programs.
- This created a streamlined workflow for care teams to access both partner SSO programs and other local community resources, all in one place.
C3’s results over the course of the demonstration pilot:
17,800+
members were referred to SSO partners
92%
of eligible members were connected to services
The future of MassHealth’s 1115 Medicaid waiver
With the January 2025 transition from Flexible Services to a new HRSN services framework, community-based organizations (CBOs) face greater operational complexity—including the need to become MassHealth providers and submit claims for reimbursement. Managing eligibility, referrals, and compliance just got harder.
Findhelp is here to simplify it.
We’ve enhanced our platform to support ACOs, hospitals, and CBOs as they navigate these new requirements—ensuring seamless eligibility verification, data standardization, and claims management.
How Findhelp supports the new HRSN framework
- Real-Time Eligibility Determination – We ingest member files or integrate with Medicaid Management Information Systems (MMIS) to enable instant member searches and eligibility checks.
- Built-In HRSN Data Standards – Our platform automates coding and data capture, mapping LOINC codes, Z codes, and state-specific HRSN data fields—eliminating manual work for CBOs.
- Claims Submission & Tracking – Reduce the steep learning curve and overhead for CBOs new to MassHealth billing. CBOs can document services, auto-generate claims, submit to health plans, and manage accounts receivable—all from a single platform.
Massachusetts ACOs & CBOs: Let’s work together
The future of HRSN service delivery demands technology that reduces administrative burden, ensures compliance, and accelerates reimbursements. Findhelp is already supporting ACOs and CBOs in navigating these changes to MassHealth’s 1115 Medicaid waiver—let’s talk about how we can help you, too.
Partner with Findhelp on your HRSN service delivery
Schedule a demo to learn how we can partner to meet the requirements of your state’s Medicaid 1115 waiver demonstration and other HRSN service delivery initiatives.
