Grant Partners

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.

County of Dukes County will provide culturally and linguistically competent enrollment assistance, referrals, and retention services for public insurance and safety net programs, with a focus on the Spanish- and Portuguese-speaking communities.

The Massachusetts Association of Community Health Workers (MACHW) will strengthen the professional identity, foster leadership, and promote the integration of community health workers (CHWs) into the health care, public health, and human services workforce. MACHW will continue to organize and empower CHWs to participate in policy and advocacy, conduct direct advocacy to ensure that CHWs are integrated into guidelines for medical homes and accountable care organizations, and will participate in advocacy coalitions and campaigns focused on health care access and payment reform.

Health Care For All (HCFA) will build a movement of empowered people and organizations to create a health care system that is responsive to the needs of all, especially the most vulnerable.  HCFA will continue its advocacy in pursuit of three key objectives: ensuring maximum enrollment in existing coverage programs, preserving and strengthening public program eligibility, and identifying and representing consumer needs within delivery system reforms.

Brockton Neighborhood Health Center will provide traditional outreach and individual assistance with applications, referrals to primary care providers, education on health plans, and assistance with annual renewals. The program will focus on local food pantries and the Plymouth House of Corrections.

The Joint Committee for Children's Health Care in Everett will provide outreach, interpretation, application assistance, and scheduling support for children and their parents, particularly in Latino and Haitian immigrant populations.

MyLink:  Community Healthlink and its hospital partners will identify 300 “high user” patients and provide them with a MyLink community support worker who will meet them in the emergency room, maintain regular telephone and in-home contact, provide assistance in meeting basic needs, help anticipate crises, and connect the patient with the appropriate level of care (primary care, home health services, or behavioral healthcare). The project expects to expand to Health Alliance Hospital in Leominster and St. Vincent Hospital in Worcester, and collaborate with dispatchers and EMTs to provide additional insight into the needs of the patients they treat and transport.

Lynn Community Health Center will develop and evaluate its Integrated Care Project, an effort that integrates primary care and behavioral health care.  It will also develop a universal care plan supported by an electronic health record.  The project will create new models of care management and coordination for the health center’s highest-risk patients.  The health center believes that more appropriate services and increased treatment compliance will result in fewer emergency room visits and inpatient hospital care, reducing overall health care costs.  Over the three-year project, the health center will target 1,000 patients who have the highest rates of emergency room visits and inpatient hospital care.  To serve these patients, Lynn will develop an intensive care management team in which primary and behavioral health providers will work together. 

Enhancing Patient Access to Primary Care:  Greater Lawrence Family Health Center will target “super-utilizers” of the emergency departments of Holy Family Hospital, Lawrence General Hospital and Merrimack Hospital.  “Super-utilizers” are identified as those who have visited the emergency department during clinical hours of operations, could have waited at least 12 hours to be seen, and have been seen at least four times within a 12-month period at one of the hospitals.  A team consisting of a family physician, a behavioral health psychologist, a nurse care manager, and bilingual and bicultural health care coaches will develop care plans for these patients. 

The Massachusetts Senior Action Council will enable the voice of seniors in pursuit of two key objectives.  First, to defend current health coverage which is essential for vulnerable seniors and people with disabilities to obtain needed services.  Second, for the development of a robust advocacy strategy for improving existing health care systems, restraining health care cost growth, and redressing current inequities caused by coverage gaps and variations in quality.

Community Action Committee of Cape Cod & Islands will ensure that eligible residents of Cape Cod and the Islands are enrolled in public health insurance programs. The program will focus on recently unemployed residents or those whose employers have eliminated health benefits or raised employee contributions beyond their ability to pay.

Boston Medical Center (BMC) will integrate a depression-screning tool into the Re-Engineered Discharge (RED) protocol, an 11-step process for reducing the risk of patients being readmitted to the hospital.  Results have shown that patients who receive RED are 30% less likely to be readmitted within 30 days of discharge.  Because further research has shown that patients with symptoms of depression are 74% more likely than those without to be readmitted in this same 30-day window, RED-Plus, as the enhanced intervention will be known, will be piloted on BMC's inpatient services for Boston Medical Center HealthNet patients, whose primary care providers are located in the 15 community health centers affiliated with BMC. 

Ecu-Health Care will provide public health outreach, application assistance, and support for accessing primary care providers. One-on-one training will educate clients on the individual mandate, minimum creditable coverage policies, and affordability regulations.