Grant Partners

South Middlesex Opportunity Council (SMOC) provides housing and supportive services to disadvantaged, homeless, single adults in three regions of the state:  MetroWest/Framingham, Central Mass/Worcester, and the Merrimack Valley/Lowell.  SMOC will evaluate the impact of its Housing First program that recognizes an immediate and primary focus on helping clients access and sustain permanent housing, to test the hypothesis that stable housing leads to improved health outcomes, and ultimately, a reduction in health costs.  Three hundred clients will be placed into housing and evaluated as part of this project.  SMOC will identify those clients with the highest service needs at entry into shelter, and then follow them into and throughout their housing placement in order to measure their health outcomes at various points along the continuum of homelessness and housing.

Project Directors: Thomas Byrne, PhD, Principal Investigator and Daniel Miller, PhD, Co-Investigator“A Data-Based Redesign of Health Care and Housing for People who Experience Chronic Homelessness” is a two year project that will assess the potential return on investment associated with several different housing intervention models for persons age 55 and above experiencing chronic homelessness. The research team plans to: describe the health care utilization patterns among Massachusetts residents over the age of 55 who are enrolled in Medicaid and experience chronic homelessness and compare those patterns to two other comparison groups, including a similar cohort who experiences homelessness on a temporary basis and a cohort who have not experienced homelessness; project health care costs over the next ten years associated with Massachusetts residents over the age of 55 who are chronically homeless and enrolled in Medicaid in the absence of a housing intervention; and analyze if/to what extent implementation of several different housing models targeted to chronically homeless adults aged 55 and older would lead to reductions in health care costs. Where applicable, the researchers will also estimate the potential return on investment associated with large-scale implementation of the housing models considered. This project will focus on Massachusetts but is expected to be part of a multi-state project involving other independent studies in California, New York, and Washington (pending funding for projects in each of these states), which share similar research objectives.

Dukes County will participate in community outreach events, and use paid and unpaid advertising and social media to promote affordable insurance information. They will develop a folder with handouts for appointments, and adapt a checklist for account set-up, enrollment and payment information, primary care provider selection, and making appointments. It will also set up reminder systems for clients with pending action steps. 

Community Action of the Franklin, Hampshire, and North Quabbin Regions will conduct outreach through four community coalitions, food pantries, and career centers.  They will screen all callers for health insurance needs and send reminders about member responsibilities to submit documentation and update information.  At enrollment meetings, Community Action will provide materials to help members stay organized and follow-up to see if they have a PCP, can access their Connector account, and have responded to any mailings. 

Cambridge Economic Opportunity Committee (CEOC) will plan outreach and enrollment activities at community locations. It will use an extensive follow-up system to address churn, ensuring that individuals have obtained the benefit they applied for and that all documents have been submitted.  It will conduct financial education and coaching to help ensure individuals can maintain their payments and minimize the risk of churn, and conduct educational coaching on health insurance literacy.

Urban Edge provides housing supportive services including public benefit enrollment, family budgeting, leadership development, connections to community, and tax preparation services.  The Family Van carries out curbside testing, health coaching, and care referrals to individuals in underserved communities, travelling directly to areas in which the need is greatest, and providing a range of preventive services and an alternative to costly emergency department visits.  Both organizations will partner with Winn Companies to analyze the impact that housing support services have on the health of families most impacted by the social determinants of health, using an Evaluation Framework for Community Health Programs. 

Fishing Partnership Health Plan (FPHP) will conduct outreach mailings and maintain presence at harbors, marinas, and trade shows, reaching fishermen and their families. They will address churn through providing a Resource Sheet with relevant deadlines, follow-up via preferred communications methods, and provide individual education sessions on health insurance literacy.

The Health Starts at Home Initiative supports four partnerships that bring together housing and health care organizations to support work that demonstrates the positive effects of stable, affordable housing to children's health outcomes, identify promising new and existing models for collaboration that can be brought to scale, decrease health care costs, and decrease costs related to homelessness.  Families eligible for participation have children under the age of 12, and are experiencing housing instability.  The evaluation partners for Health Starts at Home, Health Resources in Action and the Urban Institute, are conducting both outcome and process evaluations to measure whether and how improved housing stability affects the health of children, as well as to document successes and challenges, and develop best practices for creating these types of health care and housing partnerships. 

Ecu-Health Care will utilize broadcast and print media to inform residents of health coverage options; provide presentations to community organizations; educate area businesses about health coverage options for employees; and work with physicians’ groups and health and human service organizations to facilitate referrals. Churn will be reduced through education during one-on-one application assistance appointments and health insurance literacy is integrated into a comprehensive packet for applicants.

Massachusetts Housing and Shelter Alliance (MHSA) serves unaccompanied homeless adults throughout the state, with a primary focus on the chronically homeless.  MHSA will analyze the impact of housing as a social determinant of health among the chronically homeless population through two permanent supportive housing programs, Home & Healthy for Good and Pay for Success.  In partnership with the Commonwealth Medicine division of UMass Medical School and Analysis Group, the study will estimate the impact of participation in these programs on health care use and costs, using Medicaid claims and enrollment data. 

Hilltown Community Health Centers (HCHC) will work with small businesses, Councils on Aging, schools, employers, medical providers, and community organizations to conduct outreach, advertise in newsletters, print, and social media. They will work with the Connector to identify and target outreach to consumers who need to renew their coverage and partner with sheriff’s departments, courts and probation offices to reach recently incarcerated and court-involved individuals who experience higher rates of churn. To address health insurance literacy, they will develop consumer-friendly education tools and collateral. 

Dukes County will participate in community outreach events, and use paid and unpaid advertising and social media to promote affordable insurance information. They will develop a folder with handouts for appointments, and adapt a checklist for account set-up, enrollment and payment information, primary care provider selection, and making appointments. It will also set up reminder systems for clients with pending action steps. 

Boston Center for Independent Living (BCIL) will provide services to and seek full integration for individuals with disabilities into society. BCIL will advocate to policymakers and legislative leaders, maintain and strengthen operations for the Disability Advocates Advancing our Healthcare Rights (DAAHR) Coalition, organize the disability community against any threats to coverage or affordability, develop organizational technical expertise, and provide policy analysis and input to the field, particularly related to One Care. BCIL will also increase capacity to focus on behavioral health integration and social equity.

The National Alliance on Mental Illness Massachusetts (NAMI Mass) will strive for access to services for all who need them and end the stigma around mental illness.  Their strategies include educating families and individuals to understand their illnesses and advocating for needed services. NAMI will strengthen their policy focus on the following issues: a lack of uniform access to health-related benefits; lack of recognition of cost-effective treatment modalities by MassHealth; and inequitable treatment of disability coverage for mental illness.

The Massachusetts League of Community Health Centers (the League) will address the changes in the policy and health care environment with vulnerable populations, community health centers, and their communities.  A main goal is to analyze health care reform policies, monitor proposals for change, and educate community health centers and partner organizations. The League will also assemble health centers, community members, providers, and advocates in an action-based coalition for maintaining and expanding coverage.