Grant Partners

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.

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.

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. 

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.

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.

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. 

Whittier Street Health Center will provide eligibility assistance and coordinate care for patients, making referrals within the health center, with other health care providers, and community partners.  They will continue to foster the Building Vibrant Communities program to employ housing development residents as community health workers to assist consumers with their health and social needs.  Community health workers will be trained in patient navigation to equip consumers in connecting with primary care and other social and health services.  

Boston Public Health Commission will assist consumers in enrolling in and selecting health plans, as well as retaining coverage.  They will develop quick-guides on the new marketplace application and renewal processes, and disseminate “Health Portfolios” to consumers to track health coverage, primary care providers, and Affordable Care Act information.  “Roving Navigators” will promote access to health coverage at barbershops, auto body shops, and nail salons.

Family Health Center of Worcester will assist uninsured individuals to enroll in and maintain coverage, and connect to a primary care medical home.  They will continue weekly New Patient Orientation/Education Sessions, and expand the use of “I Speak” cards that detail useful information on the health center for patients.  Finally, they will provide individualized education and install computer kiosks for patients to use.

The Massachusetts Law Reform Institute will continue its advocacy with MassHealth and the Connector around issues of eligibility, auto-assignment of health coverage, income determinations, and the availability of resources for assisters from community-based organizations.  Additionally, it will continue its work with the Disability Advocates Advancing our Health Care Rights (DAAHR) Coalition on the One Care demonstration for dual-eligible individuals.  

Health Law Advocates will continue its advocacy work in five areas:  health care reform implementation, medical debt advocacy, children’s mental health access, access to oral health care, and pro-bono legal support.  Additionally, the organization will provide individual representation for residents who have been denied access to health care or have received unaffordable medical bills.  

Codman Square Health Center will conduct outreach and enrollment, hold a series of events to help attendees complete insurance applications, and provide orientations on available health coverage options.  Computers will be made available at the Codman Tech Center to access the health insurance marketplace, and consumers will be connected to the health center’s patient-centered medical home model to promote consumer engagement and self-sufficiency.  

Community Health Connections will conduct intensive street and shelter outreach to individuals who are homeless, providing eligibility determinations and application assistance.  They will hold “office hours” at local organizations to answer questions regarding programs, eligibility requirements, and sources of care in the community.  A “Community Collaborations” group consisting of health and human services organizations will be convened, serving the region’s homeless, to share information about the Affordable Care Act.  

Community Action Committee of Cape Cod & Islands will continue individualized “Access to Care – Navigating the Massachusetts Health Care System” educational sessions for consumers, and design a training guide identifying MassHealth mailings and navigating the complex health care system.  They will conduct a series of outreach events to educate the public on changes through the Affordable Care Act.