Grant Partners

Public Health Institute of Western Massachusetts (PHIWM) provides research and assessment, coalition-building and facilitation, and program and health policy development, with the goal of strengthening social needs, housing and health equity, specifically for low-income neighborhoods and communities of color. PHIWM will work with the region’s social and behavioral health service sectors to understand their needs and implement capacity-building strategies to respond to anticipated Accountable Care Organization patient referrals and clinical linkage programs.  Social service, housing, and behavioral health leaders seek PHIWM’s support in understanding how they can create partnerships that will enable social determinants of health to be addressed in health care settings.  

Conference of Boston Teach Hospitals (COBTH) will hire a consultant to develop and facilitate a planning process that will establish the Community Health Needs Assessment (CHNA) and Community Health Implementation Plans (CHIP) Collaborative and provide recommendations that are represented by key city stakeholders and community members, and aloow them to highlight the social and economic factors impacting the City of Boston and its neighborhoods.  This planning process follows an agreement by COBTH hospitals to collaborate on primary data collection that is shared among member hospitals of COBTH for their respective CHNAs.  In 2018, COBTH intends to conduct a single CHNA and develop a joint CHIP for all of the city in partnership with the Boston Public Health Commission and other key community stakeholders. 

Massachusetts Public Health Association is implementing the campaign phase of its Alliance for Community Health Integration (ACHI), a collaboration among state and local leaders in public health and consumer advocacy focused on ensuring that the social determinants of health are intentionally identified and addressed in Massachusetts health care transformation. Priorities include: maximizing the impact of social determinants of health on new MassHealth ACO models by ensuring availability of training and technical assistance for partners, and promoting data transparency on health-related social needs, interventions, and outcomes; advocating for changes in community benefits to strengthen alignment of hospital investments with community needs and social determinants of health; and engaging hospitals, health centers, and insurers to utilize their political clout to advance legislation that addresses social determinants of health.

Citizens' Housing and Planning Association (CHAPA) is the leading statewide housing policy and research organization in Massachusetts, and manages the On Solid Ground (OSG) Coalition, which includes organizations in housing, health, education, employment, legal services, and faith-based communities advocating for increased housing and economic stability for families, thereby improving housing, education, income and health outcomes.  CHAPA will conduct outreach and education to affect policy and systemic change at the intersection of health and housing. 

The Health Starts at Home Initiative supports four partnerships that bring together housing and health care organizations to support work that demonstrates the positive effects of stable, affordable housing to children's health outcomes, identify promising new and existing models for collaboration that can be brought to scale, decrease health care costs, and decrease costs related to homelessness.  Families eligible for participation have children under the age of 12, and are experiencing housing instability.  The evaluation partners for Health Starts at Home, Health Resources in Action and the Urban Institute, are conducting both outcome and process evaluations to measure whether and how improved housing stability affects the health of children, as well as to document successes and challenges, and develop best practices for creating these types of health care and housing partnerships. 

The Community Builders (TCB) is a nonprofit real estate developer and owner, with a mission of building and sustaining strong communities where people of all incomes can achieve their full potential.  The organization develops housing for families and seniors, invests in local businesses and public amenities that strengthen neighborhoods, and constructs or preserves hundreds of affordable and mixed-income housing developments.  TCB will commission Health Resources in Action to develop and conduct an evaluation for its Community Life program, specifically for low-income residents housed in the New Franklin Homes development in Dorchester.  Community Life is a program that addresses important social determinants of health like housing stability, early childhood education, access to healthy food, and economic stability to improve the health of residents.  Residents facce a multitude of chronic health issues, including high blood pressure and diabetes, and over half of residents report not managing their conditions.  The process will enable TCB to develop clear metrics and evidence-based strategies to improve health outcomes among its residents. 

Funding will support the On Solid Ground (OSG) Coalition, which is facilitated by Citizens' Housing and Planning Association (CHAPA), and includes advocacy organizations representing health, housing, education, employment, legal services, and faith-based communities, as well as research and philanthropic partners.  In the past year, OSG conducted gap analysis and research, publishing Observations and Findings from 31 Public Support Programs Available to Low-Income Families in Massachusetts, which identified the programmatic and administrative barriers faced by vulnerable residents of the state when they try to use such social service resources.  OSG plans to deepen its involvement, with key staff continuing to partner with the Foundation on Actions Labs and other convenings, attend hearings on Medicaid reform and related topics, and participate in coalitions that work on community benefit agreements, determination of need, Medicaid reform, and research initiatives in other states.  They will strive to increase funding and support for housing assistance and services as part of a coordinated strategy to address the social determinants of health. 

The Health Starts at Home Initiative supports four partnerships that bring together housing and health care organizations to support work that demonstrates the positive effects of stable, affordable housing to children's health outcomes, identify promising new and existing models for collaboration that can be brought to scale, decrease health care costs, and decrease costs related to homelessness.  Families eligible for participation have children under the age of 12, and are experiencing housing instability.  The evaluation partners for Health Starts at Home, Health Resources in Action and the Urban Institute, are conducting both outcome and process evaluations to measure whether and how improved housing stability affects the health of children, as well as to document successes and challenges, and develop best practices for creating these types of health care and housing partnerships. 

Urban Edge provides housing supportive services including public benefit enrollment, family budgeting, leadership development, connections to community, and tax preparation services.  The Family Van carries out curbside testing, health coaching, and care referrals to individuals in underserved communities, travelling directly to areas in which the need is greatest, and providing a range of preventive services and an alternative to costly emergency department visits.  Both organizations will partner with Winn Companies to analyze the impact that housing support services have on the health of families most impacted by the social determinants of health, using an Evaluation Framework for Community Health Programs. 

Massachusetts Association of Community Development Corporations (MACDC), in partnership with the Mel King Institute, will train community developers and offer technical assistance to help them partner with local hospitals to address the social determinants of health at the community level.  Content of the trainings include hospital Community Benefit programs, the Determination of Need program, reforms to health care under Medicaid and requirements for Accountable Care Organization models, and successful examples of partnerships between the hospital and housing communities.  This program seeks to build partnerships with community developers, as hospitals are addressing the needs identified in their own Community Health Needs Assessment processes. 

Massachusetts Housing and Shelter Alliance (MHSA) serves unaccompanied homeless adults throughout the state, with a primary focus on the chronically homeless.  MHSA will analyze the impact of housing as a social determinant of health among the chronically homeless population through two permanent supportive housing programs, Home & Healthy for Good and Pay for Success.  In partnership with the Commonwealth Medicine division of UMass Medical School and Analysis Group, the study will estimate the impact of participation in these programs on health care use and costs, using Medicaid claims and enrollment data. 

Greater Lynn Senior Services (GLSS) is a Massachusetts' designated Area Services Access Point, and the principal source for home, community-based, and long-term support services for more than 30,000 low- and moderate-income elders, adults living with disabilities, and their families/caregivers.  The organization is focused on building healthy and more livable communities, where critical home and community-based services and supports are required to promote residents' optimal independence and well-being.  GLSS, in partnership with Boston University's Center for Aging and Disability Education and Research (CADER), will develop an evaluation framework for its Kiosk for Living Well program, which deploys vibrant, mobile spaces embedded in community pulse-points that inspire consumers to participate in activities designed to promote healthier living routines.  Currently situated at four senior centers and three housing complexes, kiosks represent community hubs designed to strengthen clinical-community linkages, facilitate health care access, and provide health monitoring and assessments.  The evaluation will deliver an evidence-informed assessment of both early impact and ongoing potential of the kiosk concept as a model for integrating health care and social services.   

Friends of Jewish Community Housing for the Elderly (JCHE) provides supportive, affordable, independent senior housing in Massachusetts, and owns 1,200 apartments that are home to 1,500 low-income older adults in Brighton, Newton, and Framingham.  In collaboration with the LeadingAge Center for Applied Research, JCHE will seek to demonstrate the effectiveness of affordable housing on the quality of life for the organization's seniors, as well as an impact on costs to the government and health care system.  It will include metro Boston seniors who are low- and moderate-income with similar demographics (income, age, ethnicity, risk profile) living in subsidized housing and receiving supportive services.  The provision of housing will be studied as an intervention at three levels, using Medicaid and Medicare utilization data:  1) housing without services, 2) housing with resident service coordination only, and 3) housing with significant service enrichment. 

Massachusetts Public Health Association (MPHA) is leading a newly formed Alliance for Community Health Integration ("the Alliance"), focused on how the health care system could more powerfully impact social determinants of health.  In its inaugural year, the Alliance will implement an aggressive, multi-faceted, multi-year strategy involving significant leadership from numerous organizational partners at the local and state levels.  It will conduct key informant interviews of local grasstops and grassroots leaders that are working to improve social determinants of health at the neighborhood level, to help test and refine the Alliance concept.  The Alliance will also conduct a rigorous policy and political landscape analysis to identify opportune windows over the coming years, and recommendations on framing and community strategies needed for successful campaigns. 

South Middlesex Opportunity Council (SMOC) provides housing and supportive services to disadvantaged, homeless, single adults in three regions of the state:  MetroWest/Framingham, Central Mass/Worcester, and the Merrimack Valley/Lowell.  SMOC will evaluate the impact of its Housing First program that recognizes an immediate and primary focus on helping clients access and sustain permanent housing, to test the hypothesis that stable housing leads to improved health outcomes, and ultimately, a reduction in health costs.  Three hundred clients will be placed into housing and evaluated as part of this project.  SMOC will identify those clients with the highest service needs at entry into shelter, and then follow them into and throughout their housing placement in order to measure their health outcomes at various points along the continuum of homelessness and housing.