Grant Partners

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 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. 

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.

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.

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.

Disability Policy Consortium (DPC) will connect disability advocacy communities across the state and amplify the voices of these groups in conversations with state and federal policymakers. In so doing, DPC seeks to re-frame disability as a social rather than medical condition and to shift the focus within disability-related health care from payment to ethics. DPC will serve as a hub for cross-disability advocacy through community-based participatory action research, their co-leadership of DAAHR, and an expanded social media presence.

To revamp the organization’s website.

The National Alliance on Mental Illness Massachusetts (NAMI Mass) will work to improve access to mental health services and to reduce stigma regarding mental health conditions. Priorities include restoring state funding and reimbursement for behavioral health services and improving commercial coverage of emergency services. Additionally, NAMI Mass will work on creating a statewide mental health training program for law enforcement. To achieve these goals, NAMI Mass will conduct policy analyses, organize local chapters and peer support program members, and participate in coalitions and stakeholder alliances.

The Massachusetts Association for Mental Health (MAMH) will work to improve access to behavioral health services and health-related social services for individuals with behavioral health conditions. MAMH will analyze policies and evidence-based programs related to health, including supportive housing subsidies and criminal justice reform, and will disseminate their findings through reports and through their activities as a convener and coalition leader. MAMH will also work to expand their capacity for data collection, measurement, and reporting.

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.