Grant Partners

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.  

In their project titled “Best Opportunities for Improving Massachusetts Health within Budget Constraints,” the research team will use published cost effectiveness research and Massachusetts-specific data on current health care use to identify opportunities to reduce the use of overused low-value care and increase the use of underused high-value care.  Their simulation model will allow health care leaders to estimate total cost savings and health gains that could be achieved by reallocating resources from inefficient to efficient interventions.   

The Joint Committee for Children’s Health Care in Everett will provide application assistance and referral support, and conduct a multimedia publicity campaign to reach consumers about the Affordable Care Act.  Additional education will be provided through a multilingual helpline, website, and newsletter.  A series of educational sessions will be conducted at local community organizations on navigating the health system and using the Health Information Exchange.  

Through its Health Access Campaign, the Massachusetts Immigrant Refugee & Advocacy Coalition will advocate for all immigrants to maintain current coverage or obtain benefits under the Affordable Care Act.  It will translate and share information on health coverage options available through the federal law to educate members, policymakers, and community-based organizations that serve immigrant stakeholders.  

Healthy Lives:  Brookline Community Mental Health Center will serve 200 low-income adults living in Brookline or Boston who present with serious mental illness (schizophrenia, bipolar disorder, major depression, severe anxiety, or PTSD) and at least two chronic medical conditions (including diabetes, cardiovascular disease, or COPD).  The health center will engage patients in their care, help them coordinate the services they receive, provide wellness interventions, offer disease management programs, home visits, and individual and group counseling. The intent of the project is to help patients move from passive recipients to active participants in their health care and by doing so, reduce cost and improve quality.

Health Law Advocates will use funds to provide legal representation to low-income residents experiencing difficulty accessing or paying for needed medical services.