Grant Partners

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.

HSL has developed a depression services program, Making Real Progress in Emotional Health, to integrate behavioral health treatment with primary care and other health services to reduce the severity of depressive symptoms in seniors, and to improve overall health.  The Foundation's grant will enable HSL to expand services to patients receiving in-home care.  In 2015, HSL acquired Jewish Family and Children’s Services, which expanded HSL’s home care services by an additional 1,000 seniors (now totaling 2,000 older adults).  In contrast to seniors in supportive housing who tend to be part of a community, seniors in home care are more likely to suffer from isolation, pain, and increased debility post-hospitalization.  These stressors also increase these seniors’ susceptibility to depression.  HSL will take the lead in developing and monitoring individual care plans; tracking health outcomes in collaboration with primary care physicians from the practices treating the majority of patients; and developing additional community partnerships to ensure more comprehensive collaborative care for their patients.

LCHC has developed and implemented a fully integrated primary care and behavioral health program with co-location of services, co-management of patients by the medical and behavioral health providers through a shared care model, and utilization of shared electronic medical records through a newly-implemented Epic system.  The Foundation has supported the development, growth and improvement of this very strong behavioral health integration program, with continued funding for the health center’s response to the substance abuse epidemic in Lynn.  Building upon the learning and successes of its foundational behavioral health integration model, LCHC has developed an integrated primary care/mental health/addictions team of professionals who specialize in addictions and mental health disorders.  The team also utilizes medication to treat addictions, including Suboxone, with plans to add Vivitrol.  LCHC will expand this multi-disciplinary team by adding a psychiatrist, therapists, primary care providers, and nursing staff to serve approximately 800 patients.

Vinfen has developed Community-Based Health Homes (CBHH) for individuals with serious mental illness to integrate their primary care and behavioral health and address the disparities experienced by the population.  The CBHH model achieves close collaboration approaching an integrated practice by embedding Nurse Practitioners (NPs), Nurses (RNs) and Health Outreach Workers (HOWs) into existing community-based rehabilitation and recovery behavioral health teams, bringing primary care services directly to individuals with serious mental illness in their communities since 2012.  Over the past three years, Vinfen has been actively evaluating and piloting health technologies in an effort to integrate behavioral and primary health care for its population.  The Foundation-supported expansion program embeds two HOWs and the use of a smartphone app specifically designed to support the population into a dispersed, community-based outreach team.  A dedicated Program Coordinator will manage the program, collect data and evaluate impact.