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.

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.

The Boston Public Health Commission will use funds to train staff of city agencies and consumers on how to navigate the health care system and a newly launched web-centric resource database will be developed to help locate referral organizations.  Customized 'My Health Portfolios' will educate consumers on facts to consider when obtaining health care.

Community Health Center of Franklin County will provide a comprehensive continuum of services including community outreach, enrollment and eligibility assistance, transportation assistance, Spanish interpretation, case management, and care coordination. The health center will target residents affected by significant social and geographic barriers to care, as well as new immigrants, migrant workers, and non-English speakers.

Family Health Center of Worcester will initiate the Consumer Self-Sufficiency Program to improve access to health care and insurance coverage for low-income individuals and families, and increase patient self-sufficiency in navigating the health care system and obtaining the appropriate level of preventive and acute health care.

Massachusetts League of Community Health Centers will serve as a key resource to its membership as cost containment and payment reform continue to reshape the health care environment. The League will conduct a multi-tiered advocacy strategy on a statewide level, including analyzing and disseminating policy information, engaging its members on key issues, and collaborating with other organizations and coalitions that share community health and primary health care goals.

Caring Health Center will target refugees, immigrants, and other linguistic and cultural minority groups who face barriers to enrollment and health care navigation. The health center provides comprehensive primary medical care and dental services to residents in the medically underserved city of Springfield and its surrounding areas.

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.

Community Health Connections will provide street outreach and one-on-one application and enrollment assistance to homeless or high risk children and adults, as well as members of the Spanish- and Portuguese-speaking communities.

Lynn Community Health Center will initiate the Keep Your Care Project, a pilot study that will test the effectiveness of text messaging as an alternative to postcard and letter reminders. Those reminders are sent via the mail to remind patients to complete their annual redetermination application and submit demographic information changes to maintain their coverage.