Grant Partners

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. 

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.

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.

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.

CHL is the largest provider of mental health, substance use disorders and homeless services in Central MA, serving more than 19,000 unique individuals each year. In October 2010, CHL received a four-year SAMHSA grant to implement the Primary and Behavioral Health Care Integration (PBHCI) program to improve access to and engagement in primary care and wellness services for more than 400 adults seeking mental health and substance abuse treatment at CHL. To meet these service needs, the Wellness Center was developed at CHL wherein primary care physicians, nurses, nurse case managers and peer specialists delivered medical care and a variety of wellness interventions for adult consumersbetween the ages of 18 and 72 with behavioral health needs. Key goals of the initiative are to continue to enhance (a) care coordination and communication between the providers at the Wellness Center, the CHL outpatient clinic, and those in the community who provide other types of services to CHL consumers, and (b) electronic health record infrastructure and processes.   

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. 

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.