Meet the Alliance Partners

Alliance Partners are membership organizations, state and national agencies, health care systems and insurers, and community driven and faith based organizations, offering vital health care planning information and tools to consumers and care providers.

The Massachusetts Alliance Partners distribute the Honoring Choices structured approach to health care planning and the free, downloadable program and tools to thousands of care providers and staff within their organizations. They incorporate the Honoring Choices proven programs into their individual organizations to actively engage adults and families in health care planning.

The National Alliance Partners are working with Honoring Choices to bring best practices and evidence based programs into the state.

Meet our growing network below, and read about our exciting  joint initiatives highlighted in the blue boxes below. We welcome your participation and ideas!

Click on a link to quickly scroll down to an Alliance Partner:

Learn about the Alliance Partners and Joint Initiatives

Alzheimer’s Association, Massachusetts/New Hampshire Chapter

Julie McMurray, MA, LMHC, CDP| Senior Manager, Central Regional Office & Community Outreach  office: 617-393-2140 |

24/7 Helpline: 800.272.3900

AlzHereForYou and 24/7 Helpline

Have a questions or concern?   Click on this link, AlzHereForYou to  view a wide range of resources. And call the 24/7 Helpline. Trained staff are there to help individuals, family members and caregivers, and also health care providers and community professionals.  Working together with the Alzheimer's Association, Dementia Friendly MA, Dementia Friends and others, we will increase awareness about Alzheimer's Disease and other Dementias and offer a common sets of information and resources to adults and families in Massachusetts.

The Alzheimer’s Association mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care for all affected; and to reduce the risk of dementia through the promotion of brain health.  Our vision is a world without Alzheimer’s disease.  #ENDALZ. The Massachusetts/New Hampshire Chapter’s  five regional offices provide resources, education and support to families impacted by Alzheimer’s or other dementias. The Chapter is committed to educating and working alongside health care professionals improve their knowledge and skills to build stronger teams and deliver better care.  AlzHereForYou  has a wide range of resources. Each year, we work with more than 45,000 people in Massachusetts and New Hampshire, many of whom contact us through our 24/7 Helpline 800-272-3900.


American Cancer Society

Palliative Care Initiative

Hundreds of palliative care clinicians from large hospitals to  community programs came together over a 9 month period to forge a common language and set of tools regarding palliative care. Together we created the “Palliative Care: 5 Things to Talk About" discussion guide.  Msny thanks to Lisa Leydon, American Cancer Society, Christine McMichael, Hospice & Palliative Care Fed. of MA, Northeast Palliative Care Regional Group of the Mass Comprehensive Cancer Prevention and Control Network; Gail Merriam, MSW, MPH, and Connie Dahlin, ANP, BC, ACHPN, PFCN, FAAN, Elizabeth Collins, MD, Palliative Care Medical Director, Lahey Hospital & Medical Center.  Read More.

American Cancer Society logoThe American Cancer Society’s central mission is to diminish suffering from cancer and improve the quality of life of cancer patients throughout their continuum of care. They believe expanding early access to palliative care services is a critical step to improving the cancer journey for patients and families. The American Cancer Society, New England Region, in collaboration with Massachusetts Department of Public Health and the Comprehensive Cancer Prevention and Control Network has recently begun a series of Palliative Care Regional Forums, to improve access to palliative care for all cancer patients in Massachusetts. The Forums are being held in seven regions throughout the Commonwealth. Honoring Choices is supporting their work and developing tools to support both consumers and care providers.

American Nurses Association

American Nurses Assn-MAAmerican Nurses Association- Massachusetts (ANA-MA)is committed to the advancement of the profession of nursing and of quality patient care across the Commonwealth. ANA Massachusetts is recognized as the voice of 120,000 registered nurses in Massachusetts and supports their work through advocacy, leadership development, education and mentorship.

Asian Women for Health

Chien-Chi Huang, Executive Director

Asian Women for Health - Home | Asian Women for Health


Asian Women for Health, AWFH, is a peer-led, community-based network dedicated to advancing Asian women’s health and wellness through education, advocacy, and support. AWFH envisions a world where Asian women are well-informed, have access to care that is culturally appropriate and high quality, and inspired to live happy, healthy lives. They provide communities with critical access to free breast and cervical cancer, connect women on important health issues giving voice to their personal journeys to become inspiring agents of change, and are building an online community to share information and support while reducing language barriers and time or space restrictions.  

Atrius Health

Atrius HealthAtrius Health is a non-profit alliance of four leading community based groups: Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates, and VNA Care Network Foundation. At the core of Atrius Health is a commitment to making it easier for patients to be healthy, beginning with high quality and proactive care coordinated by your primary care physician. All groups utilize an electronic medical record to improve care coordination and communication for patients. The combined Atrius Health groups offer over 35 specialties, from obstetrics to pediatrics, including oncology, cardiology, ophthalmology, sports medicine, allergy, dermatology, surgery and behavioral health. Atrius Health serves 675,000 adult and pediatric patients in over 2.2 million visits annually to 42 practice locations.

Baystate Health

Samantha Kennedy, Advanced Care Planning Team

Download an HCM Health Care Proxy from your Patient Portal

Through my Baystate Health Patient Portal, patients can download and complete a free Honoring Choices Health Care Proxy and Personal Directive (Living Will), view & update their documents, and communicate their health care choices and preferences with their clinicians.

Baystate Health is a not-for-profit, integrated health care system serving over 800,000 people throughout western New England. Recognized nationally as a leader in the healthcare industry, Baystate Health ranks among the top 15 health systems in America. With roots dating to the founding of Springfield City Hospital in 1873, Baystate Health’s mission is to improve the health of the people in their communities every day, with quality and compassion. Baystate Health improves the health of the many diverse communities it serves through Baystate Medical Center, which is home to the area’s only adult level 1 trauma center and pediatric trauma center, as well as through Baystate Children’s Hospital, three community hospitals, home care and hospice services, a network of more than 80 medical practices and several community health centers. Baystate Medical Center is the regional campus of the University of Massachusetts Medical School, educating and training current and future caregivers to serve the community.We are working closely with Baystate Medical Center’s Advanced Care Planning workgroup to support their mission and integrate the Honoring Choices Health Care Proxy and Personal Directive into their health system, enhance multi-lingual and multi-cultural expansion of health care planning information, and support the Western MA Transitions in Care Cross Continuum, a well-established collaborative group of over 300 health care provider members.

The Betsy Lehman Center for Patient Safety

M.E. Malone, Deputy Director

Taking Care of the Emotional Needs of Care Provdiers

The Peer Support Team offers a wonderful list of resources for clinicians, care providers, and managers. Read more  under  "Partner News".

The Betsy Lehman Center fosters a statewide program of research, data analysis, and programming that engages and supports health care agencies, providers, and consumers working together to improve patient safety in care settings across the Commonwealth.  They are a non-regulatory state agency with a legislative mandate to:

  • Help state health care agencies and providers work together to keep patients safe;
  • Develop new ways for consumers to be included in a statewide program for improving patient safety;
  • Analyze data and research to support patient safety initiatives;
  • Administer an education and research program to increase awareness about medical error & prevention strategies;
  • Share information about evidence-based practices to enhance patient safety.

Boston Public Library

Sophie Leveque

Reference Librarian II, Health & Human Services Specialist


Now's The Time! Make Your Own Care Plan!

Honoring Choices MA(HCM) is collaborating with the Boston Public Library (BPL) to offer a free consumer webinar series to all its members to ensure equal access to health care planning tools. "Now's The Time. Make Your Own Plan" is a live zoom interactive webinar co-hosted by HCM and BPL,  which provides a step by step review of the HCM Getting Started Tool Kit so every adult if they choose can complete a MA Health Care Proxy and MA Personal Directive (Living Will). Free documents are available in 15 languages.

Established in 1848, the Boston Public Library is a pioneer of public library services in America. As a City of Boston historic cultural institution, Boston Public Library today features a central library and twenty-five neighborhood branches, serving nearly 4 million visitors per year and millions more online. The mission of the Library is focused on four core areas: reading and literacy, spaces and programs, reference and instruction, and special collections and cultural heritage. Their commitment to be ‘Free to All’ is carved into the façade of the Central Library in Copley Square. They are proud to welcome everyone equally regardless of gender, race, national origin, sexual orientation, faith, or economic status.  Sophie Leveque Reference Librarian II, Health & Human Services Specialist Boston Public Library  is co-hosting a quarterly free webinar with honoring Choices to help ensure all BPL consumers have equal access to no cost information and MA planning documents to make their own health care plan.


Boston Medical Center, Health Equity Accelerator

Co-Directors Thea James, MD, Vice President of Mission & Associate Chief Medical Officer, and Elena Mendez-Escobar, PhD, MBA, Executive Director of Strategy


EQTY 2023 - A Health Justice Summit

Boston Medical Center welcomes leaders & advocates to-

EQTY 2023 - A Health Justice Summit

September 14, 2023, 8am-6:30pm

Artists for Humanity, Boston MA 

Click here to Register Today!

Health equity is a complex and entrenched issue with a well-documented race-based gap when it comes to health outcomes. The Heath Equity Accelerator at Boston Medical Center, led by co-directors Thea James, MD, Vice President of Mission & Associate Chief Medical Officer, and Elena Mendez-Escobar, PhD, MBA, Executive Director of Strategy, is focused on creating holistic change to eliminate disparities in health outcomes across different races and ethnicities.

They strive to acquire an acute understanding of the challenges that communities of color uniquely face in receiving equitable healthcare, address systematic and long standing systemic racism, and transform healthcare to eliminate gaps in life expectancy and quality of life. BMC’s Accelerator has prioritized five clinical areas where there are major disparities: Pregnancy, Cancer, Infectious Diseases, Chronic Conditions, and Behavioral Health. By 2035, their goal is to “have made a demonstrable impact on racial health equity and built a model that other healthcare institutions can replicate to advance health equity across the U.S.”

As an Honoring Choices Partner, we are delighted to support the Health Accelerator’s mission and share their research and innovations with the thousands of care providers and consumers in the Honoring Choices Partners network. Together we can implement changes to close the gap on health inequalities and promote improved pathways to connect adults to timely, quality care over their lifetime. Read more here.


Blue Cross Blue Shield of MA

Anna Gosline, Senior Director of Health Policy and Strategic Initiatives

Healthy Blue Advance Care Planning Coaches

Honoring Choices(HC) is collaborating with Blue Cross Blue Shield of MA (BCBSMA) and The Conversation Project (TCP) to train BCBSMA volunteer employees as the Healthy Blue Advance Care Planning Coaches. The Coaches offer presentations to fellow associates to make a health care plan using HC Who's Your Agent? Tool Kits for quality care all through their life, and to have end of life care conversations using the TCP's Starter Tool Kits.

Blue Cross Blue Shield of MABlue Cross Blue Shield of Massachusetts (“Blue Cross”) is a community-focused, not-for-profit health plan headquartered in Boston, working with more than 31,500 Massachusetts employers and covering 2.8 million members. In addition to our corporate promise to always put our members first, we are committed to ensuring that all our members receive care that is aligned with their goals, values, priorities, and preferences at all times in their lives, especially when facing a serious illness.

Boston University School of Social Work and The Center for Aging & Disability Education and Research

Alison Montague, Program Manager, The Network for Professional Education, Boston University School of Social Work

Dahye Kim, MSW, Manager, Workforce and Curriculum Development, Center for Aging & Disability Education & Research (CADER)

Become a Health Care Planning Ambassador

The BU School of Social Work's Network for Professional Education offers the Honoring Choices MA "Become a Health Care Planning Ambassador" no cost webinar as part of their learning catalog. The webinar is available HERE

We welcome the Center for Aging & Disability Education and Research (CADER) at Boston University School of Social Work (BUSSW) as an Honoring Choices Alliance Partner. CADER is a nationally recognized training and research center dedicated to supporting individuals and organizations who provide health and social services to older adults and people with disabilities. Since 2002, CADER has led the way in the development and dissemination of evidence-informed, competencies-based online trainings and programs serving over 20,000 workers and 450 organizations across the country and globally. They offer specialized online programs in aging to learners through a portfolio of high-quality professional education opportunities including online courses, certificate programs, and webinars. Their learning catalogue can be found here.

They have included the Honoring Choices "Become a Health Care Planning Ambassador" webinar for care providers to confidently start planning conversations using the Honoring Choices Getting Started Tool Kit. The free webinar is available on The Network for Professional Education at BUSSW here. 

CADER is committed to enhancing the skills of practitioners in the field of aging and disability at all levels of experience. Their training and workforce solutions cover a wide range of topics, including key practice areas with older adults, behavioral health and aging, case management practice, and evidence-based practice skills. We partner with a variety of partners to meet the diverse, ever-changing needs of individuals and communities.  Their partners include Area Agencies on Aging, State Units on Aging, Independent Living Centers, senior centers, housing providers, behavioral health organizations, nursing homes, assisted living centers, hospitals, community health centers, social service agencies, and adult day health centers.

Read more about CADER here.


Suelin Chen, PhD

Co-Founder and CEO

Honoring Choices- Cake Joint Portal

Cake created a portal for all Massachusetts adults to access the Honoring Choices Health Care Proxy and the Honoring Choices Personal Directive on the Cake website. Now you can create, share, revise and update and securely store your documents in the cloud.

Cake is an easy way to discover, store and share your health care planning documents and end of life care choices & preferences.  You can create your documents on the Cake website and store them in the cloud. Cake makes it possible for this important information to be easily updated, accessed, and retrieved whenever it is needed. Cake has helped thousands of individuals and organizations make planning progress in not just the health care category, but also in legacy, legal/financial, and funeral considerations.  You can create your own free personal account, and view and download the Honoring Choices Health Care Proxy and Honoring Choices Personal Directive. If you already have these documents completed, you can upload your documents and securely store and share your documents and end of life care preferences. Everyone has access to the Cake cards to create your own unique profile. Click here to access the Honoring Choices portal

Cape Cod Health Care System

Alliance Partner and Community Partner

Cape Cod Hospital is our first hybrid Alliance Partner and Community Partner. They are in a unique position to distribute information to all care providers & staff within the Cape Cod Healthcare system, and bring together a 62 member Task Force of multidisciplinary professionals from organizations across the Cape, who actively engage adults in health care planning discussions, and provide or refer to care and services.

Cape Cod Hospital is both an Alliance Partner distributing information and training throughout the Cape Cod health system, and a Community Partner coordinating area care providers to provide hands-on help to adults and families. Cape Code Hospital under the direction of Tina Soarses, has brought together a dynamic 62 member Task Force of area care providers, to provide a common, unified health care planning language and set of Massachusetts tools to every consumer and care professional on the Cape. The Task Force is helping adults start planning discussions, make a health care plan, and connect adults to person-centered care all through their lifetime. We are working on several projects together. On June 1, 2017, they will host the second in the series of MOLST: Meeting the Challenge Workshops for care providers. For more information, contact Tina Soares, BSN, RN, CHPN, Quality of Life Management, VNA of Cape Cod/ Cape Cod Healthcare, tsoares@

Caregiver Homes / Seniorlink

 "What do Caregivers do?" Creating a Common Understanding

Laurie Herndon, Director, Clinician Program Innovation, contributed a downloadable informational article on the role and decision-making authority of caregivers. The article is widely used  to help adults and families understand the role and responsibilities of a caregiver, and when to consider their services.

Caregiver Homes from SeniorlinkCaregiver Homes from Seniorlink is an innovative, proven model of full-time in-home care and support for elders and individuals with disabilities that offers families a quality alternative to care that depends on facilities or home health aides. Through financial assistance, as well as dedicated care managers and nurses who provide daily support and monitoring to ensure success for both the consumer and caregiver, Caregiver Homes makes it possible for families to provide around-the-clock care for elders and those with disabilities.


CaringBridge is a global, nonprofit social network dedicated to helping family and friends communicate with and support loved ones during a health journey. CaringBridge offers free, personal, protected websites for people to easily share updates and receive strength and encouragement from their community.  CaringBridge provides control and a safe environment for people facing any health condition. Every 7 minutes, a CaringBridge website is created for someone experiencing a health journey. CaringBridge was founded in 1997 and was the first social networking site for communicating during a health event. Today, over 300,000 people visit CaringBridge daily. To learn more or start a site, visit


Coalition to Transform Advanced Care (C-TAC)

The Coalition to Transform Advanced Care (C-TAC) is dedicated to the ideal that all Americans with advanced illness receive comprehensive, high-quality, person- and family-centered care that is consistent with their goals and values and honors their dignity. We will achieve this by empowering consumers, changing the health delivery system, improving public and private policies, and enhancing provider capacity. C-TAC has a wwealth of information, tools webinars and upcoming events. Read more here.

Center for Health Impact

Joanne Calista, Executive Director

Center for Health ImpactThe Center for Health Impact (CHI) strives to create health equity through partnership and innovation – by enhancing access to quality healthcare and education, eliminating health disparities, and promoting workforce development. They specialize in Translation Services, Interpretation Services, Health Care Workforce Training, and Technical Assistance. Honoring Choices partners with CHI's Translation Services to produce all our translated care planning documents and multilingual care planning tools. Through a rigorous translation process, their skilled team of translators, editors, proofreaders and quality control specialists ensure cultural and contextual accuracy and appropriateness. CHI’s clients include government agencies, hospitals, HMO’s, community based organizations, legal practices and more. Additionally, Language Link, CHI’s innovative Interpretation Service, provides clients with well-trained and experienced interpreters to facilitate effective communication in clinical and conference settings. With the support of the MassHealth Access Program and the UMass Medical School, their language specialists facilitate communication between patients and providers within healthcare settings. We are grateful for CHI’s long standing commitment to advance health equity by helping us ensure all adults have equal access to care planning documents and tools in their primary and preferred languages.  You can read more at

Dementia Friendly Massachusetts

Patty Sullivan, Project Manager

Dementia Friendly MA InitiativeThe Dementia Friendly Massachusetts Initiative (DFMI) is a whole-community response inviting everyone to join in creating dementia friendly communities. Dementia friendly communities are safe, informed, and respectful and engage all members of the community to meet the needs of the growing number of people living with dementia to remain part of the fabric of our vibrant community life. The Massachusetts Executive Office of Elder Affairs, Jewish Family & Children’s Services and other partner organizations convened DFMI in May 2016 to provide statewide support and coordination for the efforts to help our communities better include and support individuals living with dementia and their family members, friends, and professional caregivers. DFMI aims to link communities, businesses, and organizations across Massachusetts to tools, resources, and best practices.

Dementia Friends Massachusetts: Dementia Friends Champions

Beth Soltzberg, Director

Dementia Friends is a global movement that is changing the way people think, act, and talk about dementia. Developed by the Alzheimer’s Society in the United Kingdom, the Dementia Friends initiative is underway in Massachusetts. By helping everyone in a community understand what dementia is and how it affects people, each of us can make a difference for people touched by dementia. To become a Dementia Friend, adults and families can participate in a one-hour Dementia Friends Information Session offered by a Dementia Friends Champion. You will learn five key messages about dementia and a bit about what it’s like to live with dementia. As a Dementia Friend, you turn your new understanding of dementia into a practical action that can help someone with dementia living in your community.  Visit their website  at for materials in 9 languages and for many specific communities. The website also lists ongoing opportunities to attend an information session or be trained to lead sessions. A program of Jewish Family & Children's Services.


Dementia Friends Massachusetts: Memory Cafes

Beth Soltzberg, Director

Memory Cafes in Massachusetts are a welcoming place for people with forgetfullness or other changes in their thinking, and for their family & friends, to enjoy each other’s company and to know they are not alone in facing everyday challenges. Memory Cafes meet in a variety of venues across the state.

To find a Cafe, please visit

Dignity Alliance Massachsuetts

Dignity Alliance Massachusetts

Coalition of Disability and Senior Advocacy Organizations Forms in Response to Nursing Home Deaths

Everyone deserves to live a full life with dignity.  However, Covid-19 has robbed many of that right --- in just over five months more than 5,600 people have died in 379 Massachusetts nursing homes, 88% of the 429 homes in the state, and the toll increases daily. These deaths comprise 15% of all nursing home residents in the state and nearly 66% of all Covid-19 deaths in the Commonwealth. Over 24,000 nursing home residents and staff have tested positive.  The mortality rate of infected nursing home residents is more than 22%, three times the rate of the general population. Dignity Alliance Massachusetts has formed to address the structural and systemic deficiencies which have created this public health crisis.  We are committed to implementing and expanding access to essential care improvements and living alternatives that will make the Commonwealth a model of care and living choices.   Visit the website to learn more.


Ashwini C. Bapat M.D.

Co-Founder & CEO


EpioneMD provides virtual serious illness coaching and advance care planning to individuals and telepalliative care consultations to healthcare organizations. Our team of empathic coaches comprised of palliative care-trained physicians, a social worker, and a chaplain with over 30 years of combined experience, provide virtual one-on-one coaching to individuals who are aging or living with illness, and their caregivers. We help individuals and their caregivers develop a personalized advance care plan and framework for making healthcare decisions, provide emotional and spiritual support, communicate your wishes with loved ones and your medical team, and identify additional supportive resources. We also offer caregivers support in navigating their role and ensuring they understand their loved one’s wishes. Learn more and schedule your free introductory call to see how we can help. Take our free 7-Day Advance Care Planning Challenge and join us as we walk you through the process of creating or revising your own Advance Care Plan.

Fallon Health

Ellen Bond, RN, CCM

Clinical Manager, NaviCare Program Fallon Health

Fallon Health Care Manager's Who's Your Agent? Program

Honoring Choices is working with over 60 Fallon Health care managers who provide coordinated, integrated care for seniors and individuals with complex health needs. The care managers incorporate the Who's Your Agent? Program and Tool Kits into their every day visits with adults and families to open the door to meaningful planning discussions.

Fallon Health is a leading health care services organization that supports the diverse and changing needs of their members. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, they also offer unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. The Fallon Health care managers help their members identify health needs and services and work with local community based groups and home services to keep their members receiving the highest level of care. Fallon has consistently ranked among the nation's top health plans and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. Read more about Fallon Health at

Health Law Advocates

Andrew P. Cohen

Director/Lead Attorney |

HLA Health Care Planning Ambassadors

HLA professionals are helping engage adults in simple planning conversations to ensure all adults have equal access to health care planning tools, in order to make a plan to get timely, equitable quality care that honors their care choices.

Health Law Advocates (HLA) is a public interest law firm that provides free legal assistance to Massachusetts residents with low incomes who face barriers to accessing or paying for needed medical services. HLA is committed to ensuring universal access to quality health care in Massachusetts, particularly for those who are most at risk due to such factors as race, gender, disability, age, or geographic location. Our services include:

  • Challenging denials of health insurance enrollment (commercial and public insurance)
  • Fighting denials of coverage for specific health care services (commercial and public insurance)
  • Access to health care for immigrants of any status
  • Protecting patients from illegal medical billing and collection practices
  • Obtaining access to health care through state agencies and school systems, especially for children
  • Beginning or improving special education services for children with mental health diagnoses

With its partner organization, Health Care For All, HLA combines legal expertise with grassroots organizing and policy reform to advance the statewide movement for universal health care access. Learn more at

Healthcentric Advisors

Honoring Choices New England Age-Dementia Friendly Initiative

Healthcentric Advisors is helping to co-convene a multi-state collaboration to ensure all adults living at our borders and traveling through New England receive high quality care that honors their planning documents and care choices. We are proudly supporting Healthcentric Advisor's Sepsis Awareness Train-the-Trainer Initiative.

Healthcentric Advisors is working to improve care for Medicare beneficiaries, their families and caregivers across New England. This initiative aligns with the Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Organization (QIO) Program, the largest federal health quality program. Healthcentric Advisors is convening community coalitions or providers, patients and other stakeholders. Working together, they aim to improve transitions of care for all patients, reduce unplanned hospital admissions and re-admissions and decrease the prevalence of adverse drug events.

Home Care Alliance of MA

Pat Kelleher, Executive Director

Home Care Alliance of MAThe Home Care Alliance of Massachusetts, with 40 years of experience and nearly 200 agency members across the Commonwealth, is a non-profit trade association of home care agencies that promotes home care as an integral part of the health care delivery system. Their mission is to “unite people and organizations to advance community health through care and services in the home.” The Home Care Alliance provides essential resources, innovative programs and advocacy to its members to help stay informed and thrive.

Hospice & Palliative Care Federation of MA

Christine McMichael, Executive Director

Northeast Greater Boston Palliative Care Collaborative

Hundreds of palliative care clinicians from large hospitals to  community programs came together over a 9 month period to forge  a common language and basic definitions of what is palliative care, who can access it and when, and how to start a discussion. Together they created the “Palliative Care: 5 Things to Talk About" discussion guide. The projects collaborative partners include: Lisa Leydon, American Cancer Society, Christine McMichael, Hospice & Palliative Care Fed of MA, Northeast Palliative Care Regional Group of the Mass Comprehensive Cancer Prevention and Control Network; Gail Merriam, MSW, MPH, and Connie Dahlin, ANP, BC, ACHPN, PFCN, FAAN, Elizabeth Collins, MD, Palliative Care Medical Director, Lahey Hospital & Medical Center.  Read More.

Hospice and Palliative Care Federation of MA logoThe Hospice & Palliative Care Federation of Massachusetts (HPCFM)
is a non-profit statewide membership organization that is dedicated to advancing and promoting excellence in end-of-life care. Founded in 1980, HPCFM is comprised of hospice, palliative, associate and individual members. HPCFM member hospices serves over 21,000 patients and their families a year representing 40% of all those who died in Massachusetts. HPCFM serves not only its members, but those seeking or using end-of-life services and others interested in this area.

LeadingAge MA

Elissa Sherman, Executive Director

LeadingAge MA logoLeadingAge Massachusetts, formerly MassAging, represents the full continuum of mission-driven, not-for-profit providers of health care, housing, and services for older persons in Massachusetts. Members of LeadingAge Massachusetts provide housing and services to more than 25,000 older persons in the Commonwealth each year. The mission of LeadingAge Massachusetts is to Expand the World of Possibilities for Aging. They strive for this by leading in innovative practices that transform how we care for our aging population, spear-heading cutting-edge initiatives to develop services that meet older adults’ needs and preferences, and advocating to advance the interests of the aging consumer. At their Annual Conference in May, they provide a free copy of the Health Care Proxy to each attendee to take and complete if they had not already completed one.  This year they will offer a session on “Ensuring Person-Centered Care: The Role of Aging Service Providers in Meeting the Goals and Preferences of Individuals at all Stages of Life” .

Massachusetts Advocates for Nursing Home Reform

Arlene Germain, Policy Director

Massachusetts Advocates for Nursing Home Reform

POB 560224 | Medford, MA  02156 | 800-988-4450 |

Consumer Health Equity Group

We are honored to work with MANHR, celebrating 20 years of unwavering advocacy in 2020, to improve the care, dignity and quality of life of Massachusetts nursing home residents. MANHR community advocates have also joined the Honoring Choices MA Consumer Health Equity Group to elevate the consumer voice to drive the agenda for meaningful change to eliminate health inequities.

The Massachusetts Advocates for Nursing Home Reform (MANHR), founded in 2000 by grassroots volunteers, is the only statewide consumer group working to improve the care, dignity and quality of life of Massachusetts nursing home residents.

MANHR strives to better the lives of nursing home residents through our goals: 1) advocate for public policies that support quality care & the best attainable quality of life; 2) empower & educate residents & their supporters; 3) promote best practices in care delivery; 4) inform members, interested parties & the general public on MA/national nursing home issues.

To support these efforts, MANHR represents nursing home residents in coalitions, committees, and statewide initiatives; is an active advocate in Department of Public Health stakeholder groups and in MA Attorney General quarterly meetings; and provides research to state officials and the media.  MANHR also continues to provide mentor services to our member family-run councils, operates an 800# helpline, and maintains a comprehensive website

MA Alzheimer Disease Research Center (MADRC)

Nancy Coppelman

Aging & Memory Loss Road Map Education Series

MADRC/CART is rolling out the Aging & Memory Loss Road Map Education Series at Brigham and Women’s Hospital and the second and third parts are scheduled for January 3, 2020 and February 7, 2020. Open to the public. Everyone is welcome! Email or call 857 307-0708 for more information.

The Massachusetts Alzheimer Disease Research Center (MADRC) mission is to support new research and enhance ongoing research by providing support and bringing together behavioral, biomedical, and clinical science investigators together to enrich the effectiveness of Alzheimer disease research, ultimately improving health care delivery. Conducting multi-disciplinary research at multiple sites including at the Center for Alzheimer’s Research and Treatment (CART) at Brigham and Women’s Hospital; training scientists and clinicians across institutions; and teaching and/or transferring new information concerning Alzheimer disease and related disorders within the community and among our collaborators is critical to our goals. The Outreach, Recruitment and Engagement Core’s (ORE) mission aligns with MADRC’s overall goals to improve our understanding of disease heterogeneity; diversity across education, ethnicity and socio-economic strata which affects not only the biology of Alzheimer Disease and AD-related Disorders but the clinical expression of disease as well. The ORE Core works to meet these challenges by focusing on several areas: engaging in public outreach, particularly within under-represented groups, developing liaisons with collaborators including city and state agencies and developing new strategies for engaging with the community and clinicians including developing more rapid methods to facilitate earlier diagnosis and training faculty to support education within the community.

Visit the website here. For information about other educational programming or scheduling your own, email Nancy @

MA Assisted Living Association

Massachusetts Assisted Living Association (MASS ALA)is a non-profit organization dedicated to the professionally operated assisted living residences in Massachusetts. Mass-ALA has grown to hundreds of members that include assisted living providers and associated professionals. It serves as the voice of senior living and promotes resident-centered models that respect the dignity, privacy, independence and choice of older adults. Mass-ALA provides information, education, advocacy and support on behalf of their members and the adults they serve.

Mass Caregiver Coalition and the Mass Caregiver Initiative

Massachusetts Caregiver Coalition, an Honoring Choices Alliance Partner, and the Mass Technology Collaborative  recently launched the Mass Caregiving Initiative. Their mission is to support caregivers in their communities and workplaces by partnering with the public and private sectors focusing on Employers, Communities, and Innovation. The Mass Caregiving Initiative was created to support caregivers in their communities and workplaces by partnering with the public and private sectors to drive innovation in the Commonwealth. The Initiative has three focus areas:

Employers – The Massachusetts Caregiver Coalition emphasizes helping employers support their employees who are family caregivers.

Community - We are working with partners such as the Executive Office of Elder Affairs and Mass Home Care to address the needs of caregivers and their supporting communities.

Innovation - working with partners to highlight solutions that leaders and organizations can use to lessen caregiver stress and support caregivers.  This includes an Innovations in Caregiving Webinar Series that will publicize research data and highlight innovative approaches, products, and services that respond to the data points and empower caregivers.

MA Association of Councils on Aging

"Who's Your Agent? Program For Care Providers" Webinar & Tool Kits

The MA Executive Office of Elder Affairs, Mass Home Care and Mass Councils of Aging joined forces to offer all  their care providers and staff a personalized "Who's Your Agent? Program For Care Providers Webinar, with an introduction by  Secretary Alice Bonner, MA Executive Office of Elder Affairs.

MCOA_MA Assn of Councils on Aging logoThe Massachusetts Association of Councils on Aging (MCOA). We welcome Executive Director David P.Stevens and all of the MCOA staff, colleagues and Senior Center Directors to the Honoring Choices Partner network. We are thrilled for the opportunity to support the 351 Councils on Aging (COA) with health care planning information and tools. The COA’s are at the very heart of each community serving elders and their families. We look forward to working with all the COA’s within our 6 Community Partner regions across the Commonwealth.

Massachusetts Coalition for the Prevention of Medical Errors

Paula Griswold, Executive Director

"Patient Portal Challenge" See Survey Resutls.

Working together with the MA Coalition, we designed a 1 minute survey- just 4 questions and a comment section- to start a dialogue about the value of uploading your Health Care Proxy onto your Patient Portal to view, store and update as needed. In uploading to the Patient Portal could it also automatically transfer the Health Care Proxy to your Electronic Medical Record, so all treating physicians could view and honor in a medical emergency. View survey results & comments in News/ Blog section.

MA Coalition for Prevention of Medical Errors LogoThe Massachusetts Coalition for the Prevention of Medical Errors is a public-private partnership whose mission is to improve patient safety and eliminate medical errors in Massachusetts. The Coalition’s membership includes consumer organizations, state agencies, hospitals, professional associations for physicians, nurses, pharmacists, long-term care, as well as health plans, employers, policymakers, and researchers, all with the shared goal of improving patient safety. The Coalition promotes a systems-oriented approach to improving patient safety, identifying the causes of medical errors, and developing and supporting implementation of strategies for prevention. Honoring Choices is a member of the Coalition's  Care Transitions Steering Committee, which helps communicate about the tools and webinars with related efforts to their members.

Massachusetts Coalition for Serious Illness Care

Anna Gosline, Executive Director

MOLST to POLST Transition Advisory Group

Honoring Choices is working with the MA Coalition's MOLST to POLST Transition Advisory Group to upgrade to a successful POLST Program, and help all  adults with serious illness and advancing frailty choose treatment options for end of life care that are known and honored.

MA Coalition for Serious Illness CareThe mission of the Massachusetts Coalition for Serious Illness Care (Coalition) is to ensure that health care for everyone in Massachusetts is in accordance with their goals, values, and preferences at all stages of life and in all steps of their care. The Coalition has established six core priorities including:  naming a Health Care Agent; talking with your agent, family, and providers about care goals, values, and choices;  providing the necessary training for clinicians; and building effective systems to ensure individual preferences and choices can be documented, shared, and honored in every care setting. More than ninety Massachusetts-based organizations form the Coalition and are working on shared goals to support the Coalition’s mission. In 2016, the Coalition fielded the first of a regular series of surveys measuring Massachusetts residents’ views on serious illness and end-of-life care.  The Coalition hosts an annual spring summit each year open to all. Learn more, and become a member.

MA Commission for the Blind

Wayne Levy, Director of Communications

Screen Reader Accessible Planning Documents Initiative

With the guidance and expertise of MA Commission for the Blind, the Honoring Choices Health Care Proxy and Personal Directive are screen reader accessible and a fillable pdf. Screen reader allows low vision adults have increase access to these planning documents to start to make their own health care plan.

The Massachusetts Commission for the Blind (MCB) provides the highest quality vocational and social rehabilitation services to individuals who are blind, and vocational rehabilitation services to qualifying individuals with low vision, leading to independence and full community participation. MCB accomplishes this critical mission by working in partnership with consumers, families, community rehabilitation providers, health care providers, and employer partners. MCB has collaborated with Honoring Choices on informational training to MCB staff as well as offered technical assistance on accessible materials for the training including fillable Health Care Proxy and Personal Directive forms that can be read with a screen reader. Click here.

MA Conference, United Church of Christ

Rev. Ellie Richardson, Associate Conference Minister for Lay and Clergy Leadership Development

MA Conference of United Church of ChristThe Massachusetts Conference of the United Church of Christ (MACUCC) will help bring Massachusetts-based health care planning information and documents to their 370 churches and 70,000 members across the Commonwealth. “Any one of us, church goers or not, is likely to face times of having to make difficult care decisions” says Rev. Ellie Richardson, Associate Conference Minister for Lay and Clergy Leadership Development. “If we are in partnership in these decisions early on with our family, friends, and care providers, the difficult decisions when they come can be made easier.” We’ll provide MACUCC with educational materials and programs for every adult and family in all congregations to have equal access to the full range of health care planning information and tools at no cost. Each church also becomes an integral part of their local Honoring Choices Community Partner Network.

MA Executive Office of Elder Affairs

"Who's Your Agent? Program For Care Providers" Webinar & Tool Kits

The MA Executive Office of Elder Affairs, Mass Home Care and Mass Councils of Aging joined forces to offer all  their care providers and staff a personalized "Who's Your Agent? Program For Care Providers Webinar, with an introduction by  Secretary Alice Bonner, MA Executive Office of Elder Affairs.

MA Executive Office of Elder AffairsThe Massachusetts Executive Office of Elder Affairs. We support Secretary Alice Bonner and the EOEA staff in their commitment to help older adults and people with disabilities live and thrive. We are collaborating with Mary DeRoo, RN, BSN, MSM, Director of Home and Community Programs, EOEA. “Our mission is to give people choice” says Ms. DeRoo, “and to empower adults to be in control of the care they want, even when they can’t advocate for themselves.” We are providing information and tools to support and enhance the work of the 29 Elder Service Agencies (also known as ASAP’s, Aging Service Access Points and AAA’s, Area Agencies on Aging) throughout the Commonwealth.

MA Health & Hospital Association

Patricia Noga, Vice President of Clinical Affairs

"Healthcare Planning Throughout Your Life"

The MA Health & Hospital Association (MHA) promotes healthy living for all MHA employees and all employees of MHA member hospitals to make a health care plan starting with a Health Care Proxy. They provide easy access to the "Getting Started Tool Kit" and comprehensive health care planning information for adults through their Patient Care Link

MHA_MA Health and Hospital Assn logoThe Massachusetts Health & Hospital Association (MHA) is a voluntary, not-for-profit organization comprised of hospitals and health systems, and related organizations and members with a common interest in promoting the good health of the people of the Commonwealth. The MHA’s mission is to advance the health of individuals and communities by serving as the leading voice for all Massachusetts hospitals and healthcare systems. Through leadership in public advocacy, education and information, MHA represents and advocates for the collective interests of its members and supports their efforts to provide high quality, cost effective and accessible health care.

MA Healthy Aging Collborative

James Fuccione, Executive Director


Working Towards an Age-Dementia Friendly Massachusetts & New England

We are working  together to  support the meaningful involvement of seniors in Age-Friendly Communities through our Ambassador Programs and seek to improve health outcomes working together with the Honoring Choices Community Partners with a focus on diverse communities. We will also reach out to our neighboring states to help ensure adults living on our borders and traveling through New England/New York can access quality care that honors their choices and explore a New England initiative for healthy aging.

The Massachusetts Healthy Aging Collaborative (MHAC), a collection of more than 100 agencies and organizations committed to advancing healthy aging and age-friendly communities throughout the state, promotes policies and practices that are inclusive, relevant, and enhance the quality of life for people of all ages. MHAC also promotes best practices in healthy aging that benefit all aspects of a person’s life, including being active and having meaningful involvement in the community, to feel safe and secure and access programs that reflect diversity and heterogeneity, and to be proactive in managing one’s health care. The Collaborative is taking the lead to help communities become Age-friendly to better meet the needs of their older residents, including those living with dementia, by considering the environmental, economic, and social factors that influence the health and well-being of older adults. MHAC is also playing a central role in the Age-Friendly State effort.

Massachusetts Health Quality Partners (MHQP)

Barbra Rabson, Executive Director

Massachusetts Health Quality Partners (MHQP) is an independent, non-profit organization that brings together key stakeholder groups (providers, payers and patients) in Massachusetts healthcare to help provider organizations, health plans and policy makers improve the quality of patient care experiences throughout the state. We do this by measuring and publicly reporting non-biased, trusted and comparable patient experience data; sharing tools, guidelines and best practices to help support improvement efforts; and catalyzing collaboration to find breakthrough solutions to shared challenges. MHQP has useful resources for consumers including:

Resources for Empowered Patients, a comprehensive listing of resources to manage your health and get answers to your questions, click here; and,

Healthcare Compass, to help patients compare primary care doctor’s offices and find the right provider. click here

To read more about MHQP’s collaborative and innovative work click here

Mass Home Care

Lisa Gurgone, Executive Director

"Who's Your Agent? Program For Care Providers" Webinar & Tool Kits

The MA Executive Office of Elder Affairs, Mass Home Care and Mass Councils of Aging joined forces to offer all  their care providers and staff a personalized "Who's Your Agent? Program For Care Providers Webinar, with an introduction by  Secretary Alice Bonner, MA Executive Office of Elder Affairs.

Mass Home Care logoMass Home Care is a network of thirty agencies dedicated to helping adults live in their community with the highest level of functioning, in the least restrictive setting, for as long as possible. Mass Home Care represents the Aging Services Access Points, know as ASAPs, and area agencies which provide information and referrals, direct services and often protective services to adults in their community. The Mass Home Care website offers an highly informative monthly newsletter called “At Home” for consumers and care providers.


Samantha Morton, Executive Director

COVID-19 Ditigal Digest for MA and RI

MLPB's COVID-19 Digital Digest is an open-access tool to help workforce colleagues navigate law and policy changes due to the COVID-19 pandemic. It is intended to provide guidance and problem-solving strategies to address a range of key HRSN needs.

MA Digital Digest

Ri Digital Digest

MLPB believes in the power of justice to advance health. Medical-Legal Partnership | Boston is an interdisciplinary team of health care staff, attorneys, and paralegals who integrate legal assistance into the medical setting as a vital component of patient care. By combining the strengths of law and medicine, MLP | Boston addresses the complex social determinants of patients’ health and ensures that low-income patients are able to meet their basic needs for food, housing and utilities, education and employment, health care, and personal and family stability and safety.

Massachusetts Medical Society

Candace L. Savage | Manager, Health Policy and Public Health Outreach

MMS helped launch the first MOLST: Meeting the Challenge Workshop Series

The Massachusetts Medical Society (MMS) joined with Honoring Choices to co-host the first in a series of five MOLST: Meeting the Challenge Workshops in the Conference Center at Waltham Woods. Their collaborative work helped opened the door to a statewide dialogue with interdisciplinary care providers to build a more responsive process for all adults on a serious illness journey. The MMS Committee on Geriatric Medicine, continues to lend their expertise  and guidance on improving serious illness care and improving MOLST process.

Massachusetts Medical Society logoMassachusetts Medical Society (MMS) is the statewide professional association for 25,000 physicians and medical students. They are dedicated to educating and advocating for the patients and physicians of Massachusetts. MMS offers online CME courses and live events that award continuing medical education credits. The Society, under the auspices of NEJM Group, publishes the New England Journal of Medicine, a leading global medical journal and web site, and NEJM Journal Watch alerts and publications covering 13 specialties. Honoring Choices was thrilled to co-host and launch the first-ever MOLST: Meeting the Challenge Workshop series. We’ll be working together to standardize and improve access to Massachusetts health care planning documents and tools for all care providers and consumers in the Commonwealth.

MA Senior Care Association and MA Senior Care Foundation

Tara Gregorio, Executive Director

MA Senior Care FoundationThe Massachusetts Senior Care Foundation is the research and education affiliate of the Massachusetts Senior Care Association, whose members include more than 500 nursing and rehabilitation facilities, assisted living residences, residential care facilities and continuing care retirement communities. The Foundation promotes innovative tools, services, programs and research related to clinical and workforce quality across the continuum of care for older adults and people with disabilities. It is at the forefront of addressing some of the toughest issues impacting the health and safety of older adults and people with disabilities.

Massachusetts Taskforce to End Loneliness & Build Community

Sandra Harris

State President, AARP MA

The Massachusetts Taskforce to End Loneliness & Build Community is a statewide coalition dedicated to ensuring that all residents of the Commonwealth feel connected to their community and enjoy a strong sense of social well-being. Convened by AARP Massachusetts, the Taskforce consists of 80+ members representing 45+ organizations, including state- and city-level governments, nonprofits, academic institutions, advocacy groups, startups, and other partners. Learn more about the Taskforce's initiatives and impact at

National POLST

Bringing National POLST into Massachusetts

As a National Honoring Choices Alliance Partner, National POLST helps us bring best practices and the most current information, webinars, and tools to Massachusetts consumers and care providers. 43 states currently participate, voluntarily, in the governance of National POLST. National POLST can provide assistance to overcome our implementation challenges as we make changes to our MOLST form and process.

National POLST Paradigm logoPOLST is a national movement implemented at the state level. It is an approach to advance care planning for patients who are considered to be at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which may include advanced frailty. The POLST process emphasizes eliciting, documenting and honoring patients’ preferences about the treatments they want to receive during a medical emergency or as they decline in health. These treatment wishes are documented on a portable medical order called a POLST form. In September 2019, National POLST released a National POLST Form along with patient guides, a Guide for Health Professionals, and other materials; states must adopt this form for it to be completed in the state.  Having a national standard and form will greatly help honor patient treatment wishes throughout the country, offer evidenced-based tools, and help foster research and quality assurance activities to improve the POLST process.


Respecting Choices

COVID-19 and Advance Care Planning

Respecting Choices® is an internationally recognized, evidence-based model of advance care planning (ACP) that creates a healthcare culture of person-centered care—care that honors an individual’s goals and values for current and future healthcare.

Just in time! Respecting Choices® Offers Suite of Open-Source Care Planning Tools in Response to COVID-19

Respecting Choices logoPeople who are considered high-risk for coronavirus-related complications are feeling especially vulnerable. Respecting Choices has developed a toolkit for clinicians to engage in proactive conversations about treatment preferences before a medical crisis. There are also tools for consumers and Health Care Agents. The Respecting Choices® COVID-19 tools and resources below will support these important conversations. They are currently free and open to all based on the Creative Common License.

For Clinicians:

For Individuals and Health Care Agents

Tools to support specific treatment decisions in high risk individuals

Click here to see the full suite of tools, information and  guides.


Senior Whole Health, a Magellan Company

Patricia Jennings, Manager, Sales & Marketing

Health Care Planning Ambassadors Engage in Culturally Sensitive Conversations

We've partnered with Patricia Jennings and her dedicated team to use the Honoring Choices translated Health Care Proxy and Personal Directive with their members and families. As Ambassadors, the team will host bi-lingual community events to offer up-to-date health care planning information and documents to Spanish and Portuguese speaking members to help adults make a plan.

Senior Whole Health, a Magellan Company, works to maximize the quality of life, health, security and independence of their members. They assist their members and families understand the complex world of healthcare, by helping to manage their care and arrange for them to receive the services they need. Senior Whole Health works to meet the challenges of those who don't speak English while being sensitive to the cultural diversity of the more than 30 different languages our members speak. Some of the Senior Whole Health staff have been certified as Honoring Choices Health Care Planning Ambassadors and will use the translated health care planning tools and documents to start powerful planning conversations and help adults get connected to care that reflects their goals, values and care choices.


Pediatric Advanced Care Team (PACT) at Boston Children’s Hospital and Dana-Farber Cancer Institute

Lauren Cramer, MSW, LICSW

Pediatric Advanced Care Team (PACT)

Boston Children’s Hospital | Dana-Farber Cancer Institute

Pediatric Palliative Care

We are working with Lauren Cramer, MSW, LICSW, to share PACT expertise with Honoring Choices Partner Network and the adults and families they help. We'll develop informative fact sheets on Pediatric Palliative Care, and Guardianship Issues for Pediatric Seriously Ill Patients.

The Pediatric Advanced Care Team (PACT) at Boston Children’s Hospital and Dana-Farber Cancer Institute is a team of interdisciplinary clinicians with expertise in pediatric palliative care, who add an extra layer of support to the care of children with serious illness and their families.  Established in 1997, PACT is the oldest continuously running pediatric palliative care program in the country.

The PACT team includes physicians, pediatric nurse practitioners, program nurses and social workers, works closely with families to develop comprehensive care plans based on their wishes and priorities. In most cases, these include managing pain and symptoms; facilitating communication with the child’s care team; enhancing quality of life with emphasis on meaningfulness and improving coordination of care across settings.  PACT opens channels of communication within the family, provides comfort and support, and helps guide decision making and advance care planning that honor a family’s values. PACT also assists with guardianship needs when our pediatric patients with significant medical complexity and neurological impairment age into adulthood. Clinicians are available 24 hours a day to consult in any setting, from hospital to clinic to home.

We are delighted to work with Lauren Cramer, MSW, LICSW, Pediatric Advanced Care Team (PACT), who will jointly develop informational fact sheets on Pediatric Palliatives Care, and Guardianship and Seriously Ill Patients.  We will collaborate with the Honoring Choices Partner Network to ensure better care coordination and smoother transitions for seriously ill patients and their families.

Contacting PACT


Lauren Hartwell, MPH

Senior Program Manager, Population Health Management Capabilities

Advance Care Planning Inititative

Point32Health launched a crucial Advance Care Planning intervention that ensures members’ health care goals are understood and honored. Honoring Choices is supporting Point32Health organization-wide initiative with our structured approach to planning, co-branded tool kits for easy downloads,  staff and professional training to support the Advance Care Planning intervention for its members, care teams, and everyone in their  diverse communities.

Point32Health — the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan — is working to guide and empower healthier lives for everyone.

Point32Health’s purpose is to guide and empower healthier lives for everyone. In support of this purpose, a key initiative was launched in 2022 to systematically deploy an Advance Care Planning intervention focused on ensuring members' health care goals are understood and documented to make sure the care they receive is the care they want. Honoring Choices MA is partnering with Point32Health to support the Advance Care Planning intervention for its members, care teams, and the wider community. We are providing both health Care Planning Ambassador training to staff to start simple planning conversations, and the Engage Adults in Seamless Conversations from Simple to Serious Illness webinar, to help members with chronic and serious illness, Advance care planning is an essential tool in empowering members through their life journey. Through the lens of health equity and addressing social determinants of health, Point32Health’s interdisciplinary care team model aims to support advance care planning across all populations to enhance quality of life. More specifically, the interdisciplinary care team model aims to ensure members have advance directives in place to promote care plan alignment with member wishes, identify members who could benefit from an advance care planning conversation, and understand when and how to facilitate a referral to palliative care service or hospice care.



Western MA Transitions in Care Cross Continuum, (WM TICCC)sponsored by Baystate Health

Jodi Kashouh, MS, RN-BC, CNL, Healthcare Quality Specialist, NSQIP/TICCC Coordinator, Baystate Medical Center

To learn more please contact Nancy Remillard at

MOLST Meeting the Challenge Workshop and Survey for Holyoke & Western MA

Members of the WM TICCA competed a first-ever survey to better understand the challenges of implementing MOLST. From the survey results, we collaborated to create regional goals to improve care deliver for all adults with serious advancing illness. The regional goals  were address  in the Sept 19, 2017 MOLST : Meeting the Challenge Workshop. Training in serious illness conversations will follow.

Western MA Transitions in Care Cross Continuum logoThe Western MA Transitions in Care Cross Continuum (WM TICCC), sponsored by Baystate Health, is a well-establish collaborative group of over 300 health care provider members. Their mission is to increase communication with all providers who touch the lives of adults and seniors across the continuum of care, in order to offer the best possible person-centered care and help prevent avoidable hospital re-admissions. This dynamic and committed group includes physicians, nurses, nurse care managers, emergency services personnel, primary care clinicians, short term care, long term and rehabilitation care providers, hospital and health system professionals, home care, visiting nurse and hospice care professionals and many others. They welcome interested care providers from the Holyoke, Springfield and all of Western Massachusetts to be part of their collaborative. The WM TICCC meet every other month, 6 times a year, to discuss ways to improve communication, work on shared challenges, and develop strategies for working with high risk patients.