Grant Partners

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. 

Community Action of the Franklin, Hampshire and North Quabbin Regions will assist eligible consumers with applications, offer education about health access services over the phone, and provide financial assistance assessments.  Referral linkages with area providers will also be enhanced.  

Massachusetts Public Health Association (MPHA) will focus on community health integration and improving the built environment. MPHA will work with the Alliance for Community Health Integration to ensure that social determinants of health are adequately addressed, in particular through community investments, support for ACOs from MassHealth, and health care institutions’ internal policies.

Massachusetts Senior Action Council will advocate for health care access for the over 65 population.  It will advocate for its constituents around growing out-of-pocket costs and affordability, expanding access to community-based long-term care by eliminating disparities in eligibility for personal care attendant services, and ensuring adequate funding for home care.  Finally, the organization will increase awareness of and streamline enrollment for existing senior health care programs.

County of Dukes County will provide enrollment assistance at local community organizations to assist consumers in setting up Health Information Exchange accounts, completing applications, checking statuses and making updates.  They will also develop and disseminate information on the Affordable Care Act, with a focus on immigrants and tribal members.  Finally, social media, paid and free media will be used to reach members of the general public on health coverage options.