Grant Partners

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.

The Massachusetts Law Reform Institute will advocate on the following key issues: ensuring affordable and accessible health care for vulnerable populations, improving the administration of public coverage programs, ensuring Affordable Care Act implementation benefits low-income and vulnerable populations, protecting the rights and enhancing services for those dually eligible for Medicaid and Medicare. The program will ensure elders have access to services to prevent or delay institutionalization and that consumers have a voice in health care reform.

Hilltown Community Health Centers will assist clients to access and maintain health insurance coverage, aiding them in learning how to stay enrolled in the public programs for which they are eligible. The program will also connect clients with a primary care physician and address prescription costs.

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.