Grant Partners

Brockton Neighborhood Health Center (BNHC) will target high risk patients, defined as those having had two or more emergency department visits and/or psychiatric hospitalizations within six months, and/or patients presenting to the urgent care department two or more times within six months without consistent follow-up with a primary care provider. BNHC’s Primary Care Behavioral Health Model aims to increase patient access to behavioral health services, enhance coordination between primary care and behavioral health, and improve health outcomes. Partners include Good Samaritan Medical Center and Brockton Hospital, inpatient psychiatric units, community mental health clinics, and insurance companies.

Judge Baker Children's Center (JBCC) will implement the Modular Approach to Therapy for Children (MATCH) in four outpatient clinics in the Greater Boston area as a step toward bringing the model to scale in Massachusetts.  In addition, JBCC will compare the costs of treatment using MATCH with typical treatment costs at the participating sites.  MATCH will be utilized to treat children with multiple complex disorders, including some combination of anxiety, depression, post-traumatic stress, and disruptive conduct, including the problems associated with attention deficit-hyperactivity disorder.  Treatment Response Assessment for Children (TRAC) will be used as an outcome measurement system that guides clinicians through the implementation of MATCH.  

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.

Visiting Nurse Association of Greater Lowell will deliver home health care services, self-care education and coaching, and tele-monitoring to high-cost patients identified by the Lowell General Physician Hospital Organization (PHO) and Lowell Community Health Center. The project will serve 100 “high utilizers” in its first year and will triple in size by its third year. Targeted patients will be those diagnosed with congestive heart failure, chronic obstructive pulmonary disease, or diabetes. In-home assessment, coaching, and monitoring will be provided to patients who do not qualify for these services under current payment and benefit guidelines because they are not homebound and do not have acute, but rather chronic conditions. The project’s goal is to demonstrate the cost-effectiveness of these services.

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.  

A Collaborative Practice Model for Improving Pediatric Mental Health Value:  The Alliance Foundation for Community Health will develop a new method of identifying youth at risk for low quality/high cost mental health treatment. The sample for this study will be drawn from the 101,000 youth under age 20 insured by Network Health. The project will also look within diagnosis groups to compare treatments and expenditures across race/ethnicity, language, geography, and other characteristics. In the second phase of the effort, the project will identify primary care providers who have the largest number of high-expenditure youth and work with them and families to develop more cost-effective approaches to treatment.

Mercy Medical Center’s Health Care for the Homeless program (Mercy HCH) will collaborate with hospital emergency departments in Hampden, Hampshire, and Franklin counties to “re-direct” homeless persons who are “high-end utilizers” of emergency department services to access health care services through Mercy HCH’s clinical team.  Mercy knows the area’s homeless well and has documented cases where individuals are going to emergency rooms more than 20 times per month. Mercy HCH staff will work with these homeless individuals to obtain stable housing and resolve chronic conditions such as substance abuse and mental health issues.  Over the three-year grant period, the five participating hospital emergency departments will “re-direct” 120 homeless individuals to more appropriate care through the program.

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.  

Inpatient admissions that originate in the emergency department (ED) result in a significant portion of total health care spending each year, yet there is both wide variation in admission patterns and little understanding of best practices for post-ED care management and potential cost savings. In their project “Identifying Best Practices to Reduce Hospital Admission from the Emergency Department,” the research team will complete an in-depth study of three common conditions leading to admissions from the ED. By analyzing top-performing hospitals, the researchers will develop strategies and best practices around improving care and reducing costs.

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.  

Holyoke Health Center will serve 300 patients at high-risk for preventable hospitalization, re-hospitalization, unnecessary emergency department visits, or adverse drug events due to diabetes. The project will begin with identifying patients with diabetes with an unnecessary emergency room visit and recent hospitalization at Holyoke Medical Center, or eight or more prescriptions for diabetes.  A partnership with the Massachusetts Medicaid program will identify high-cost patients and work to understand how to predict which are amenable to disease management programs, leading to more effective, lower-cost services.

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.