Grant Partners

BCMHC's Healthy Lives program, created in 2011, is designed to increase primary care and behavioral health access for patients with co-occurring serious mental illness and multiple chronic conditions.  The patient-centered model leverages intensive care management strategies to improve access, integrates care, and helps reduce barriers to treatment for patients with complex needs.  In addition to operating a community-based care management model – including home visits, and individual and group counseling – the program introduces self-care and wellness activities for patients to become increasingly more engaged in their own health.  Healthy Lives, which received Foundation grant funding in 2015, serves low-income seriously mentally ill adults living in Brookline, Roxbury, Brighton, Allston, and most recently Dorchester and Mattapan, with at least two chronic medical conditions (such as diabetes, cardiovascular disease or COPD).  Work to date has shown that Healthy Lives significantly improves health outcomes and reduces avoidable ED visits for participants. The goal is to serve 250 to 300 patients over three years.

With support from the Foundation, EBNHC will focus on expanding behavioral health services for children and adolescents (ages 5 to 21) who are seen in Pediatrics, Family Medicine and the health center’s School-Based Health Center.  In 2014, the Pediatric and Family Medicine Departments served a total of 15,498 patients up to age 21, and the number of child and adolescent patients served continues to increase.  EBNHC's two newly hired child/adolescent psychiatrists will be able to fully treat and manage, and track and measure, the care of children and adolescents with mild to moderately severe depression and anxiety disorder, and integrate this care with a range of medical conditions.  EBNHC has historically only been able to refer pediatric patients with behavioral health issues to community providers where there are challenges associated with long wait times due to psychiatric provider shortages, as well as geographic and linguistic barriers.  Expanding on-site psychiatric capacity also will help to facilitate care planning for patients following psychiatric hospital discharge.

Since 2012, Lahey Health Division of Primary Care and Lahey Health Behavioral Services have collaborated to embed behavioral health clinicians in five community primary care practices, sharing medical records, and using the Collaborative Care Model (CCM), a team decision-making model of care.  Through this grant, Lahey Health Behavioral Services proposes a multi-faceted, multi-site expansion of its integrated CCM approach, by adding two community primary care practices (Gloucester and Beverly); introducing CCM in one Lahey Health System obstetrics practice; establishing CCM in one Lahey Health System pediatrics practice; piloting reverse integration at the Lahey Health Behavioral Services community mental health center in Salem; and expanding screenings of primary care patients across all of these sites to identify higher-risk patients and track outcomes.  Lahey Health Behavioral Services will also use tele-psychiatry to enable consulting psychiatrists to serve more patients, particularly for more rural, isolated sites, such as Gloucester, where there is a lack of access to specialty services.

The PPOC launched its Behavioral Health Integration program in 2012 and now has 41 practices participating.  The focus of this initiative is to provide substance abuse prevention and treatment services to adolescents and young adults (up to age 25) and their families at PPOC practices in Lowell and Wareham.  This funding will help expand PPOC’s effort to help practices with high-risk populations detect, treat, and manage substance abuse issues, and make referrals to community-based substance abuse care when needed.  The expansion will enhance the learning community curriculum to offer five additional hours of training on substance use, and ensure that the collaborative behavioral health integration teams have an embedded integration and clinical support specialist with substance abuse expertise via the PPOC's partnership with the Adolescent Substance Abuse Program (ASAP) at Boson Children’s Hospital.

With Foundation grant funding in 2015, CHC of Cape Cod used a combination of national best practices and center-designed strategies to develop a risk stratification tool to identify high-risk patients with significant behavioral and medical health co-morbidities, uncontrolled chronic diseases, a history of frequent hospitalization, and a history of frequent ED visits in order to implement a more comprehensive and effective model of integration.  The risk stratification tool has enabled the health center to create a high-risk registry that is fully operational and key to helping the center to achieve full integration.  With this three-year grant, CHC of Cape Cod will focus on patients who have screened for one or more behavioral health conditions, with the goal of improving access to ongoing behavioral health services for at least 1,000 patients who may benefit from an integrated care approach.  The health center will expand complex care management and quality improvement staff, and increase family involvement with care.