Grant Partners

To purchase nutrition and menu planning software for use by newly hired Dietician.

Health Law Advocates (HLA) will focus on improving health care access for vulnerable populations by providing direct legal services and advocating to state policymakers. Their direct legal service work will inform community outreach efforts, education programs, policy analyses, and legislative proposals. In their advocacy work, HLA will pay particular attention to children with disabilities, immigrants, and transgender individuals, and to issues related to behavioral health care access. Additionally, they will defend MassHealth members against federal Medicaid changes and ensure access to services for ACO-enrolled MassHealth members.

The Massachusetts Organization for Addiction Recovery (MOAR) will work to reduce stigma against addiction and to increase behavioral health care access and integration. Their efforts will center on increasing access to timely treatment to reduce overdose risk, as well as access to long-term treatment; advocating on behalf of populations disproportionately affected by addiction; and integrating peer support services into mainstream care. MOAR will conduct community organizing and outreach, participate in coalitions, and expand peer-oriented educational programs.

To upgrade to a new phone system.

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.

Boston Public Health Commission will maintain referral systems with community partners; host enrollment sessions throughout the city with a focus on the East Boston and Dorchester communities; leverage social media and local cable access; scale up flyering in census tracts with the highest rates of uninsured, with an emphasis on local businesses and community organization; and develop a multilingual plain language form that outlines when and how a consumer needs to update the state with pertinent information to maintain coverage.                                                                                          

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.

Community Care Cooperative (C3) will create a peer-to-peer learning model through which community health centers (CHCs) can participate in, and contribute to, the development of best practices for CHCs operating within an accountable care organization environment. C3 will coordinate the learning sessions and use participant feedback to ensure their utility to CHCs.

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. 

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 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.

To purchase six computers, a laptop and updated software, to enable more efficient outreach and enrollment. 

To upgrade the organization's IT infrastructure to include a remote services system that will improve the coordination of behavioral health services for clients, and ensure security of medical records.

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.

Boston Center for Independent Living (BCIL) will represent the interests of individuals with disabilities to policymakers and health care delivery system leaders. BCIL will work to ensure the availability of funds for accessible medical equipment, the continuation of funding for One Care plans, and the stability of MassHealth’s partnership with community-based organizations. BCIL will partner with other organizations in representing the disability community to accountable care organizations. Additionally, BCIL will continue its involvement with the Disability Advocates Advancing our Healthcare Rights (DAAHR) Coalition, focusing on social determinants of health.