Meeting Senior Care Options (SCO) and OneCare members where they are

When Shannon Timilty talks about care management, she doesn’t start with systems or checklists. She starts with people.

A registered nurse with more than a decade of experience, Shannon works with members in Mass General Brigham Health Plan’s One Care and SCO (Senior Care Options) programs. These programs are for people who are eligible for both Medicaid (MassHealth) and Medicare. One Care plans are for those who are aged 21-64, and SCO is for those who are aged 65+.
Shannon’s job sits at the intersection of clinical care, problem-solving, and human connection. And that’s what she loves about it; no two days look the same.

We spoke with Shannon about what members really need, where gaps may exist, and why empathy, boundaries, and persistence all matter.

Q: What brought you to this work?

Shannon Timilty: I’ve been a nurse for more than 10 years, with a background largely in behavioral health. I’ve worked in nonprofit settings and in insurance before, doing similar care management work, especially with One Care members.

I joined Mass General Brigham Health Plan right as this program launched, which was exciting. A lot of our team had worked together before, so there was already trust there. When you’re doing work this complex, having a strong team makes a huge difference.

Q: What does it take to be effective in this role?

Shannon Timilty: You must be able to put yourself in the members’ shoes. That’s really the core of it.

You’re trying to understand what their day-to-day life looks like—the barriers they’re dealing with, what they’re working toward, what might feel overwhelming. If you don’t take that perspective, it’s very hard to truly help someone.

It’s about listening, staying flexible, and meeting people where they are.

Q: Why is in-person care such an important part of that?

Shannon Timilty: Because you see so much more.

For a while, everything was done over the phone. Now that we’re back in the field, it’s a huge benefit. When you’re face to face—whether it’s in someone’s home, at a doctor’s office, or even at a coffee shop—you get a much clearer sense of their situation.

You pick up on things you might not catch otherwise. And just as important, it helps build a real relationship.

Q: How does that relationship actually start?

Shannon Timilty: It usually starts small.

If someone is guarded, I’m not going to jump straight into an assessment. I try to find something we can connect on—something simple and human.

I met with a member recently on a very hot day, and she was drinking iced tea. We started talking about that. It turned into a real conversation, and by the end of the visit, she was much more open. From there, we could start talking about her health and what she needed.

That’s how trust is built.

Q: Once you’ve built that trust, how do you figure out the right level of support?

Shannon Timilty: Everyone starts with an assessment, and from there we tailor the approach.

Some members are very independent—they may just want occasional check-ins. Others are much more medically or behaviorally complex and need ongoing, hands-on support from an RN.

The goal is to match the level of care to the person. There’s no one-size-fits-all model here.

Q: Members often come in expecting a lot of help. How do you balance support with independence?

Shannon Timilty: That balance is really important—and sometimes challenging.

There are members who want us to do everything for them, whether that’s making phone calls or scheduling appointments. And while we absolutely help and guide them, there are limits.

My job isn’t to take over their life. My job is to help them stay as independent as possible.

That means setting boundaries. For example, I’m not going to sit on hold for 20 minutes to schedule an appointment someone can schedule themselves. But if they’ve tried multiple times and something isn’t working, I’ll step in and help.

It’s about encouraging autonomy while still being there when it really matters.

Q: What happens when members struggle to follow through on care?

Sometimes members want help but don’t follow through on what’s required—whether it’s making calls, attending appointments, or sticking with a program. And that can affect their ability to get services.

For example, with day programs or behavioral health providers, if someone repeatedly misses appointments, they can be discharged. Then we’re back at square one trying to reconnect them to care.

So part of the work is helping people stay engaged and consistent, even when it’s difficult.

Q: What are some of the biggest barriers dually eligible special needs members are facing right now?

Shannon Timilty: Access and coordination can be big barriers.

There are fewer straightforward options for certain types of support now, especially for some One Care members. Getting services in place can involve multiple steps, referrals, and agencies. That’s a lot for anyone to manage—especially if they’re dealing with health issues.

Another major barrier is access to providers. Some members want in-person care, but many providers are only offering telehealth. Others lose access because they’ve missed too many appointments.

It’s rarely just one issue. It’s usually several things layered together.

Q: How much of this work is shaped by behavioral health needs?

Shannon Timilty: A lot—especially with One Care members.

There’s often a combination of medical complexity and behavioral health needs. That can affect everything from motivation to follow-through to how someone engages with care.

With SCO members, the focus tends to be more medical. With One Care, behavioral health plays a much bigger role in what we’re managing day by day.

Q: We often hear that isolation is a major issue. Are you seeing that firsthand?

Shannon Timilty: Yes—both in obvious and less obvious ways.

Some members are very isolated and may have little to no regular contact with others. I’d say maybe 10–15% of the members I work with fall into that category.

But beyond that, there are many more who have family but still rarely leave their homes. They’re not fully engaged in the world around them, and that impacts their health in a big way. They’re less likely to go to appointments, less likely to stay connected to care.

And while there is interest in being more social, the options can be limited—especially for younger members who don’t fit into traditional programs like senior centers.

Q: How does technology factor into all of this?

Shannon Timilty: It’s a major need.

A significant portion of members struggle with technology—whether it’s using a smartphone, accessing the internet, or navigating basic systems tied to their benefits. I’d estimate close to half of the members I’ve worked with need some level of tech support.

And that has real consequences. If you can’t navigate a portal, schedule something online, or use a benefit card, that becomes a barrier to care.

Q: Which benefits make the biggest difference in members’ daily lives?

Shannon Timilty: Transportation is huge.

Getting to medical appointments—and even non-medical errands—can be life-changing. Members also have access to rides for things like grocery shopping or getting out of the house, which helps with independence.

And the fact that there are no copays is also incredibly important. A lot of members are on very limited incomes, so removing that financial barrier makes it much easier for them to access care consistently.

Q: What do you wish more people understood about this kind of care?

Shannon Timilty: That it’s more than just having insurance.

Members don’t just have coverage—they have access to a team that can help them navigate challenges in their lives. That includes nurses, care coordinators, and people with specialized knowledge in things like housing or community resources.

A lot of people don’t realize how much support is available to them. And if we don’t have the answer, we’ll do everything we can to find it.

Q: You mentioned earlier that your team has different areas of expertise. How does that help members?

Shannon Timilty: It means we can connect people with very specific, practical help.

Everyone on the team has a bit of a niche. Someone might know housing resources really well. Someone else might understand utility assistance programs or local services in a particular area.

So when a member has a need, we’re not starting from scratch. We can tap into that collective knowledge and find solutions faster.

Q: What might surprise people about your role as a nurse?

Shannon Timilty: That this is nursing.

A lot of people think nursing only happens at the bedside in a hospital. But there are so many different ways nurses support patients.

This is one of them. It’s just happening out in the world—helping people manage their health, navigate systems, and stay as independent as possible.

Q: What keeps you motivated in this work?

Shannon Timilty: The fact that it’s always different—and that it matters.

This isn’t routine work. Every member has a unique situation, and every day brings something new to solve. It can be challenging, but it’s also very rewarding when you’re able to help someone move forward, even in a small way.

That’s what makes it worth it.

Want to learn more?

If you or someone you know is eligible for Medicaid (MassHealth) and Medicare, they may benefit from the help of a SCO or One Care dual special needs plan (DSNP) by Mass General Brigham Health Plan. To learn more, call 888-897-8947 (TTY 711). We’re available 8 a.m. to 8 p.m. ET, Monday through Sunday, October 1 – March 31 and 8 a.m. to 8 p.m. ET, Monday through Friday, April 1 – September 30.