Grant Partners

To hire a strategic planning consulting firm, Cambridge Concord Associates.

Project Directors: James Maxwell, PhD, Director of Research and Policy (Principal Investigator) and Pat Fairchild, MA, Vice President of JSI US Division“An Assessment of CHCs’ Implementation of Alternative Payment and Delivery System Reforms” will assess the current status and readiness of Community Health Centers (CHCs) to implement payment and delivery system reforms as well as to identify the primary barriers and facilitators to implementing these reforms. Relying on qualitative data collected through key informant interviews among staff at 18-20 CHCs and quantitative data available through the Uniform Data Set (UDS) from the Health Resources and Service Administration (HRSA), the research team plans to: identify the financial incentives and structural requirements being placed on CHCs based on the key components of their contracts for Medicaid’s Primary Care Payment Reform Initiative (PCPRI) and with Medicaid Managed Care Organization (MCO) plans; document the current status of CHCs in implementing components of payment and delivery system reforms; highlight and elucidate the primary barriers and facilitators to implementing reforms; and analyze the extent to which risk-based contracting and alternative payment reforms are associated with changes in CHCs’ costs and revenues. 

Whittier Street Health Center will provide eligibility assistance and coordinate care for patients, making referrals within the health center, with other health care providers, and community partners.  They will continue to foster the Building Vibrant Communities program to employ housing development residents as community health workers to assist consumers with their health and social needs.  Community health workers will be trained in patient navigation to equip consumers in connecting with primary care and other social and health services.  

Family Health Center of Worcester will assist uninsured individuals to enroll in and maintain coverage, and connect to a primary care medical home.  They will continue weekly New Patient Orientation/Education Sessions, and expand the use of “I Speak” cards that detail useful information on the health center for patients.  Finally, they will provide individualized education and install computer kiosks for patients to use.

To purchase new computers, upgrade its telephone systems, create staff email addresses, and install back-up and antivirus systems.  

Vinfen is two years into a three-year Center for Medicare & Medicaid Innovation (CMMI) grant to develop 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 Vinfen CBHH model achieves close collaboration approaching an integrated practice by embedding nurse practitioners  (NPs) – provided by Commonwealth Care Alliance (CCA) and backed by their primary and specialty medical care – into established Community-Based Flexible Support (CBFS) and outreach teams, funded by the Department of Mental Health. Vinfen has partnered with Bay Cove, North Suffolk and Brookline Community Mental Health Center to create the CBFS teams where the embedded NPs carry a caseload of up to 40 very medically complex adult patients. The NPs are supervised by CCA’s clinical director and behavioral health is provided by the above-mentioned partners with Vinfen also serving as the overall project coordinator for this integrated care model.The teams all include Health Outreach Workers (HOWs) that are employed by each of the community behavioral health providers. They assist the NPs with care coordination and wellness management. The use of an innovative telehealth technology system called Health Buddies allows remote monitoring of psychiatric and medical conditions, and increases the efficiency of the NPs. The HOWs train and support the clients in the use of the telehealth system and assistance with self-management. The program utilizes the Integrated Illness Management and Recovery (IIMR), a health self-management program that incorporates evidence-based health and wellness practices with psychiatric recovery interventions.

To purchase 16 iPad minis for case managers to record health records.

 To hire a grantwriter.

To purchase an electronic health records system, medical equipment, and nursing supplies.

Hilltown Community Health Centers will assist with applications and annual eligibility reviews and connect patients with primary care providers.  They will provide monthly public education sessions on health coverage options for consumers, and adapt their electronic medical record to establish a referral system across departments.  Educational materials will be developed on the changes in the health insurance marketplace.  Finally, they will work with small businesses in the community that may be eligible for health care tax credits through the marketplace. 

To purchase equipment for education and training purposes for the Breast Pride Project.

MyLink:  Community Healthlink and its hospital partners will identify 300 “high user” patients and provide them with a MyLink community support worker who will meet them in the emergency room, maintain regular telephone and in-home contact, provide assistance in meeting basic needs, help anticipate crises, and connect the patient with the appropriate level of care (primary care, home health services, or behavioral healthcare). The project expects to expand to Health Alliance Hospital in Leominster and St. Vincent Hospital in Worcester, and collaborate with dispatchers and EMTs to provide additional insight into the needs of the patients they treat and transport.

To hire a statistician consultant who will develop a framework for analyzing data on patient clinical outcomes and satisfaction, as well as pediatrician education, referral patterns and satisfaction as obtained from integration efforts between primary care and mental health services.  

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.  

Brockton Neighborhood Health Center (BNHC) will target high risk patients, defined as those having had two or more emergency department visits and/or psychiatric hospitalizations within six months, and/or patients presenting to the urgent care department two or more times within six months without consistent follow-up with a primary care provider. BNHC’s Primary Care Behavioral Health Model aims to increase patient access to behavioral health services, enhance coordination between primary care and behavioral health, and improve health outcomes. Partners include Good Samaritan Medical Center and Brockton Hospital, inpatient psychiatric units, community mental health clinics, and insurance companies.