Grant Partners

Lynn Community Health Center (LCHC) has developed and implemented a fully integrated primary care and behavioral health program with (a) the co-location of services, (b) co-management of patients by the medical and behavioral health providers through a ‘shared care’ model, and (c) utilization of a shared EHR. There are five integrated health teams, each with five to nine primary care providers of various types (i.e. family medicine, internists, nurse practitioners, etc.), two to three licensed behavioral health therapists, a psychiatrist or advanced practice psychiatric nurse practitioner to work with the PCPs in prescribing psychotropic medications, and clinical assistants and nurse case managers for care coordination and management of complex patients with multiple co-morbidities and high ED utilization. The health center has a fully integrated EHR with complete patient information available to all providers involved in a patient’s care. Screening tools, including PHQ-2, PHQ-9 and SF-36 are templates in the system. This allows for tracking a patient’s screening scores, and data reporting for quality improvement and evaluation. LCHC utilizes the Quality Improvement (QI) process to identify issues and opportunity for improvements, which are presented and discussed at Integration Team meetings. A team is then designated to undertake a QI project to clarify the problem, utilize the available data to measure the impact of proposed changes, and test the changes using Plan-Do-Study-Act (PDSA) cycles. Successful solutions are then spread throughout the other Integration Teams for adoption as a best practice. This model allows patients to access behavioral health services through their primary care team, effectively reducing the barrier of stigma and ensuring timely access to appropriate care.

Community Action of the Franklin, Hampshire and North Quabbin Regions will assist eligible consumers with applications, offer education about health access services over the phone, and provide financial assistance assessments.  Referral linkages with area providers will also be enhanced.  

 To hire a grantwriting coach.  

Health Law Advocates will continue its advocacy work in five areas:  health care reform implementation, medical debt advocacy, children’s mental health access, access to oral health care, and pro-bono legal support.  Additionally, the organization will provide individual representation for residents who have been denied access to health care or have received unaffordable medical bills.  

To provide a gatekeeper training on a suicide prevention model.

Through its Health Access Campaign, the Massachusetts Immigrant Refugee & Advocacy Coalition will advocate for all immigrants to maintain current coverage or obtain benefits under the Affordable Care Act.  It will translate and share information on health coverage options available through the federal law to educate members, policymakers, and community-based organizations that serve immigrant stakeholders.  

Lynn Community Health Center will provide enrollment assistance and conduct monthly outreach activities at local health fairs and cultural events.  They will collaborate with health and human service providers to provide off-site outreach and enrollment services.  Monthly education sessions will be conducted on health coverage options using a Patient Navigation Guide.  

Community Health Programs will conduct a multi-pronged outreach effort throughout Berkshire County to educate consumers on affordable insurance options utilizing its mobile medical van.  They will conduct workshops for local community organizations to reach self-employed individuals and businesses.  A key focus will be on assisting individuals with the tax filing process, as the Modified Adjusted Gross Income is utilized for determining eligibility.  Finally, a campaign will be developed to educate individuals about appropriate use of the emergency room and primary care.  

Disability Policy Consortium (DPC) will support the civil rights of people with disabilities by providing a unified voice for the community. DPC will promote consumer education and networking, community organizing, grassroots advocacy, policy promotion, and collaborative projects with government and nonprofit entities. It will continue its work with the DAAHR coalition and its Implementation Council, provide cross disability advocacy for access to health care, protect consumer choice and control, influence the implementation of One Care, integrate behavioral health into its work, and prioritize research focused on individuals with disabilities.

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.