Grant Partners

Bay Cove Human Services (Bay Cove) is the sole provider of emergency behavioral health services for all of Cape Cod, and to the Islands through partnerships with Gosnold and Martha’s Vineyard Community Services. Bay Cove will hire two new clinicians and a Certified Peer Specialist to provide wrap-around care for people with behavioral health needs. Additionally, Bay Cove will expand relationships with public and private entities that encounter people with behavioral health needs to ensure clients’ needs are met appropriately and in a timely fashion. 

Brien Center for Mental Health and Substance Abuse Services (The Brien Center) offers a variety of services for people with substance use and co-occurring disorders. The Brien Center partners with Berkshire Health Systems where all psychiatric providers are contracted with the hospital system and are embedded in its programs. The Brien Center will hire a Program Manager and Care Coordinator to ensure same-day access for outpatient services and develop the capability to address urgent and emergent needs on-site.  

Lahey Health Behavioral Services (LHBS) Emergency Services Program provides rapid assessment and immediate stabilization services to people in need in the greater Lowell area. The grant will help to enhance their urgent care clinic by introducing telemedicine for real-time psychiatric prescribing, using community health workers to assist clients following an emergent or urgent evaluation, and developing an integrated HER to improve crisis treatment and follow-up planning.

Community Healthlink (CHL) in Worcester is one of only three Massachusetts Department of Public Health/Bureau of Substance and Addiction Services licensed Behavioral Health Urgent Care Centers. CHL is affiliated with the UMass Memorial Health Care system, and works closely with St. Vincent Hospital’s emergency departments, and addiction treatment providers, such as Spectrum Health Systems and AdCare. CHL will restore the 24/7/365 access, and all operational enhancements that entails, and conduct an assessment of all opportunities for reimbursement. Additionally, CHL will hire a Medication Assisted Treatment (MAT) clinician to bridge clients, gain telemedicine capabilities, and build a team of Certified Recovery Coaches.

Clinical & Support Options, Inc. (CSO) operates an Emergency Services Program (ESP) In Hampden, Hampshire and Franklin counties. They provide comprehensive community-based behavioral health services for adults with a range of outpatient, day treatment, psychosocial rehabilitation and care management services. The team will focus their planning year on developing a sustainable model for expanding behavioral health urgent care access to psychopharmacology, providing community-based expedited medical clearance, and enhancing ESP/urgent care and police coordination.

Boston Medical Center (BMC) has served as the lead agency for the Boston Emergency Services Team (BEST) since 2003. BEST is the Metro Boston Emergency Services Program, working in collaboration with Bay Cove Human Services, North Suffolk Mental Health Association and Massachusetts General Hospital. BMC will establish an Advisory Group to work closely with a Leadership Committee to develop a master strategic work plan to address issues that will lead to the creation of an expanded behavioral health urgent care system. 

HSL has developed a depression services program, Making Real Progress in Emotional Health, to integrate behavioral health treatment with primary care and other health services to reduce the severity of depressive symptoms in seniors, and to improve overall health.  The Foundation's grant will enable HSL to expand services to patients receiving in-home care.  In 2015, HSL acquired Jewish Family and Children’s Services, which expanded HSL’s home care services by an additional 1,000 seniors (now totaling 2,000 older adults).  In contrast to seniors in supportive housing who tend to be part of a community, seniors in home care are more likely to suffer from isolation, pain, and increased debility post-hospitalization.  These stressors also increase these seniors’ susceptibility to depression.  HSL will take the lead in developing and monitoring individual care plans; tracking health outcomes in collaboration with primary care physicians from the practices treating the majority of patients; and developing additional community partnerships to ensure more comprehensive collaborative care for their patients.

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.

HSL has developed a depression services program, Making Real Progress in Emotional Health, to integrate behavioral health treatment with primary care and other health services to reduce the severity of depressive symptoms in seniors, and to improve overall health.  The Foundation's grant will enable HSL to expand services to patients receiving in-home care.  In 2015, HSL acquired Jewish Family and Children’s Services, which expanded HSL’s home care services by an additional 1,000 seniors (now totaling 2,000 older adults).  In contrast to seniors in supportive housing who tend to be part of a community, seniors in home care are more likely to suffer from isolation, pain, and increased debility post-hospitalization.  These stressors also increase these seniors’ susceptibility to depression.  HSL will take the lead in developing and monitoring individual care plans; tracking health outcomes in collaboration with primary care physicians from the practices treating the majority of patients; and developing additional community partnerships to ensure more comprehensive collaborative care for their patients.

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.

HSL has developed a depression services program, Making Real Progress in Emotional Health, to integrate behavioral health treatment with primary care and other health services to reduce the severity of depressive symptoms in seniors, and to improve overall health.  The Foundation's grant will enable HSL to expand services to patients receiving in-home care.  In 2015, HSL acquired Jewish Family and Children’s Services, which expanded HSL’s home care services by an additional 1,000 seniors (now totaling 2,000 older adults).  In contrast to seniors in supportive housing who tend to be part of a community, seniors in home care are more likely to suffer from isolation, pain, and increased debility post-hospitalization.  These stressors also increase these seniors’ susceptibility to depression.  HSL will take the lead in developing and monitoring individual care plans; tracking health outcomes in collaboration with primary care physicians from the practices treating the majority of patients; and developing additional community partnerships to ensure more comprehensive collaborative care for their patients.

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.

The CHA Collaborative Practice Model was developed in 2011 to support children with mental health and substance abuse treatment needs at the Windsor Street Clinic to test the concept that greater and earlier integration of care would improve their physical health. The program is focused on: improving behavioral health services for at-risk children and adolescents by providing timely access to culturally competent evaluation and treatment; enhancing integrated care between pediatricians and mental health providers, including increased understanding of unique family cultures and social dynamics that impact the child’s health; improving family engagement in behavioral health treatment, and building better communication between providers and parents; providing greater outreach and follow-up processes with the children and their parents, through outreach from and involvement of two tri-lingual family support specialists;  reducing unnecessary expense associated with treatment delays or poor quality of care; and, expanding the integrated care model throughout other clinics in the CHA system.

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.

The Boston Medical Center (BMC) Campus Clinic of the BHCHP opened in 2008 and serves more than 4000 patients each year; 72% of whom had at least one mental health diagnosis and 77% of whom had either a diagnosis of substance use disorder or a history of overdose. Since opening this site, BHCHP has focused on coordinated care across disciplines and has co-located primary care and behavioral health services. Behavioral health clinicians and psychiatrists are embedded in primary care to promote ease of access for patients, reduce stigmatization, and enhance the level of consultations across disciplines. Behavioral health clinicians have created dedicated “open access” appointments to accommodate referrals from primary care, same-day appointments, and walk-ins.