Grant Partners

 To support the organization’s doula program.

To purchase three laptops and support staff training for an electronic health records (EHR) system.

Health Care for All (HCFA) will focus its advocacy on achieving an affordable, accessible health care system for all Massachusetts residents. HCFA-led coalitions will work on behalf of consumers, addressing issues such as health reform implementation, oral health, children’s health, and health equity. HCFA will remain the coalition leader for the Campaign for Better Care, Oral Health Advocacy Task Force, and the Affordable Care Today (ACT!!) Coalition.

To support the redesign of HLA's website. 

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. 

To produce culturally competent patient education information on vision loss conditions.

The Department of Family Medicine and Community Health (FMCH), operates primary care practices in which Family Medicine residents are trained alongside clinical health psychology trainees. The development of the integrated behavioral health curriculum and clinical practice has been guided by Alexander Blount, EdD, a nationally recognized leader in advancing integrated primary care. The Center for Integrated Primary Care (CIPC), which he established and runs, is a resource that most of the applicants for this grant have utilized for training their team members. This grant supports integrated care in two of the three family practice residency sites – Hahnemann Family Health Center in Worcester and Barre Family Health Center in the East Quabbin region – and the efforts to use data to assess and improve the role of behavioral health in these practices. Both clinics screen for depression using the PHQ-9, as well as a ten item audit for screening for anxiety, PTSD and physical pain.  The centers have had behavioral health clinicians practicing in the clinics for the past 20 years. In the past four years, these practices have coalesced into more organized integrated models that are leveraging their co-located services to deliver patient-centered care.  Each center has NCQA recognition as Level 3 Patient Centered Medical Homes, and both are participants in the state’s Primary Care Payment Reform Initiative (PCPR).

The Massachusetts Law Reform Institute will continue its advocacy with MassHealth and the Connector around issues of eligibility, auto-assignment of health coverage, income determinations, and the availability of resources for assisters from community-based organizations.  Additionally, it will continue its work with the Disability Advocates Advancing our Health Care Rights (DAAHR) Coalition on the One Care demonstration for dual-eligible individuals.  

To develop a new and updated brochure advertising the availability of health care services.

To support the costs of creating a toolkit to replicate a model of arts-based group therapy sessions.   

The Joint Committee for Children’s Health Care in Everett will provide application assistance and referral support, and conduct a multimedia publicity campaign to reach consumers about the Affordable Care Act.  Additional education will be provided through a multilingual helpline, website, and newsletter.  A series of educational sessions will be conducted at local community organizations on navigating the health system and using the Health Information Exchange.  

To purchase an autoclave for its dental clinic in Worcester.

CHC of Cape Cod is a patient-centered medical home that has organized its 15,000 patients into primary care teams consisting of physicians, nurse practitioners, nurses, behavioral health counselors, and non-clinical support personnel for the purposes of providing comprehensive integrated care. The health center is implementing a center-wide risk stratification system to identify the most at-risk patients. They are utilizing a combination of national best practices and center-designed tools to identify patients with significant behavioral and medical health co-morbidities, uncontrolled chronic diseases, increased risk for hospitalization, and a history of frequent ED visits. This grant will help support the full implementation of the risk stratification process, and a Complex Care Management program, which a RN has recently been hired to lead. Patients with such indicators as CVD malignancies, positive M3 screens (screens for depression, PTSD, anxiety, bipolar disorder, suicidal thinking, and functionality), a positive SBIRT screen, active drug or alcohol dependency, frequent hospitalizations, difficulty with medication management, and other issues will be treated through the Complex Care Management program. Other patients with lower risk indicators will receive individualized care management from their usual providers and the integration teams, as described above.  Integrated care teams will design care plans with the active involvement of the patient and their family members; progress and follow-up plans will be documented. When a patient with complex behavioral health needs is referred to another community partner (e.g. Gosnold, Bayview, Falmouth Hospital, Cape Cod Behavioral Health), the health center tracks to see if the patient schedules an appointment, and requests a ‘release of information’ to include in the patient’s EHR for better continuity of care. 

Fishing Partnership Health Plan will educate households on the Affordable Care Act, targeting “family health brokers” and community leaders to be navigators in providing frontline education and enrollment assistance.  Seminars and trainings will be offered at shore side processing plants, industry meetings, occupational safety training seminars, and settlement houses, complete with a training curriculum for all navigators.  The “Do You Love a Fisherman?” campaign will be launched with marketing materials, services, and incentives targeting spouses and family members.  

Dimock’s approach to delivering integrated care is to focus on interventions designed for specific patient segments – pediatrics, adult medicine, and OB/GYN. Integrated care practices are at different levels of maturity, with pediatric integration having begun in 2011, adult medicine in 2012, and OB/GYN in October 2013. The health center has more 14,000 patients, and expansion of integrated care to adult medicine and OB/GYN marks the launch of routine screening for depression of all patients with the PHQ-9 instrument. As part of universal prevention protocols, patients with no initial behavioral health symptoms will have periodic screenings during medical appointments. Those at risk will receive appropriate behavioral health approaches through co-management with primary care providers (PCPs) and resource coordinators (RCs). Others will require basic interventions, such as peer specialist-led groups for brief episodic interventions from the behavioral health team. Those patients with a mental health disorder will receive treatment from the full behavioral health team (Medical Social Worker, psychiatrist, therapist, and/or substance use clinicians), in partnership with PCPs and RCs. The integrated team will coordinate care with external specialists for patients with severe mental illness who require subspecialty, intensive or home-based care.