Grant Partners

Caring Health Center will implement an extensive media and grassroots community outreach campaign to promote enrollment via multilingual television, radio, newspaper, print, social media, and website advertisements; deliver outreach at numerous community events and venues; support MassHealth members impacted by the Accountable Care Organization transition, increasing knowledge and awareness of new coverage options; develop and facilitate multilingual discussion groups to understand health system challenges; and develop facilitators’ guides, educational handouts, and a survey instrument to assess consumers’ understanding of public health insurance availability, policies, and literacy.

Greater New Bedford Community Health Center will educate patients on practices that will help them obtain and maintain coverage, including an overview of the enrollment process, action steps needed, and key deadlines; set-up a secure drop-box for patients to deposit documentation to expedite the collection and application processes; develop reminder cards that highlight important dates, deadlines, and outstanding documentation; proactively review copies of patients’ notification letters from MassHealth and the Connector to provide targeted assistance for those denied for coverage; and target outreach at self-pay patients, which the health center is seeing at increased rates, to discuss coverage options and assist in the enrollment process.

The Dimock Center will utilize its practice management system to run registries of individuals who might be at risk of losing their coverage based on insurance transitions; lead workshops and information sessions at the health center and with community partner agencies to educate patients on how to apply for, enroll in, and maintain health coverage; notify patients within four to six weeks of application to ensured they received their coverage confirmation letter, remind them of any expiration or renewal dates, and confirm next steps to ensure coverage is maintained; set up alerts in the electronic health record to notify staff of coverage expiration dates a few weeks prior to flag patients that need help with renewal applications.

The Community Builders (TCB) is a nonprofit real estate developer and owner, with a mission of building and sustaining strong communities where people of all incomes can achieve their full potential.  The organization develops housing for families and seniors, invests in local businesses and public amenities that strengthen neighborhoods, and constructs or preserves hundreds of affordable and mixed-income housing developments.  TCB will commission Health Resources in Action to develop and conduct an evaluation for its Community Life program, specifically for low-income residents housed in the New Franklin Homes development in Dorchester.  Community Life is a program that addresses important social determinants of health like housing stability, early childhood education, access to healthy food, and economic stability to improve the health of residents.  Residents facce a multitude of chronic health issues, including high blood pressure and diabetes, and over half of residents report not managing their conditions.  The process will enable TCB to develop clear metrics and evidence-based strategies to improve health outcomes among its residents. 

Project Directors: Megan Sandel, MD, MPH and Diana Cutts, MD

“Children's HealthWatch - Housing Vital Sign” is a one year project to develop a three-question screening tool to identify housing instability – to be called a “Housing Vital Sign.” While there is growing interest by health care providers in connecting patients to services that address social determinants of health, providers struggle to systematically identify which patients are in need of these services. There are currently no validated measures for universal use by health care providers for identifying housing hardships. This project aims to address that gap. Building on their experience developing and validating a two-question screening tool for food insecurity (Hunger Vital Sign™), the research team will leverage its database of nearly 60,000 patients to identify combinations of up to three housing instability questions with the highest association with adverse health and developmental outcomes among families with young children.

Dukes County will participate in community outreach events, and use paid and unpaid advertising and social media to promote affordable insurance information. They will develop a folder with handouts for appointments, and adapt a checklist for account set-up, enrollment and payment information, primary care provider selection, and making appointments. It will also set up reminder systems for clients with pending action steps. 

Cambridge Economic Opportunity Committee (CEOC) will plan outreach and enrollment activities at community locations. It will use an extensive follow-up system to address churn, ensuring that individuals have obtained the benefit they applied for and that all documents have been submitted.  It will conduct financial education and coaching to help ensure individuals can maintain their payments and minimize the risk of churn, and conduct educational coaching on health insurance literacy.

Community Action of the Franklin, Hampshire, and North Quabbin Regions will conduct outreach through four community coalitions, food pantries, and career centers.  They will screen all callers for health insurance needs and send reminders about member responsibilities to submit documentation and update information.  At enrollment meetings, Community Action will provide materials to help members stay organized and follow-up to see if they have a PCP, can access their Connector account, and have responded to any mailings. 

Urban Edge provides housing supportive services including public benefit enrollment, family budgeting, leadership development, connections to community, and tax preparation services.  The Family Van carries out curbside testing, health coaching, and care referrals to individuals in underserved communities, travelling directly to areas in which the need is greatest, and providing a range of preventive services and an alternative to costly emergency department visits.  Both organizations will partner with Winn Companies to analyze the impact that housing support services have on the health of families most impacted by the social determinants of health, using an Evaluation Framework for Community Health Programs. 

Fishing Partnership Health Plan (FPHP) will conduct outreach mailings and maintain presence at harbors, marinas, and trade shows, reaching fishermen and their families. They will address churn through providing a Resource Sheet with relevant deadlines, follow-up via preferred communications methods, and provide individual education sessions on health insurance literacy.

Project Director: Susan Crandall, PhD

“Inventory of Types of Social and Human Services in Massachusetts” is a one year project that will inform developing MassHealth accountable care organizations and others about the vast array of social and human services available in Massachusetts that support social determinants of health including: housing, food, transportation, fuel assistance, income assistance, and workforce development. The research team will develop a comprehensive overview of these programs to educate health care providers about how to readily leverage and refer to these programs when seeking to care for the holistic needs of their patients.

Ecu-Health Care will utilize broadcast and print media to inform residents of health coverage options; provide presentations to community organizations; educate area businesses about health coverage options for employees; and work with physicians’ groups and health and human service organizations to facilitate referrals. Churn will be reduced through education during one-on-one application assistance appointments and health insurance literacy is integrated into a comprehensive packet for applicants.

The Health Starts at Home Initiative supports four partnerships that bring together housing and health care organizations to support work that demonstrates the positive effects of stable, affordable housing to children's health outcomes, identify promising new and existing models for collaboration that can be brought to scale, decrease health care costs, and decrease costs related to homelessness.  Families eligible for participation have children under the age of 12, and are experiencing housing instability.  The evaluation partners for Health Starts at Home, Health Resources in Action and the Urban Institute, are conducting both outcome and process evaluations to measure whether and how improved housing stability affects the health of children, as well as to document successes and challenges, and develop best practices for creating these types of health care and housing partnerships. 

Massachusetts Public Health Association (MPHA) is leading a newly formed Alliance for Community Health Integration ("the Alliance"), focused on how the health care system could more powerfully impact social determinants of health.  In its inaugural year, the Alliance will implement an aggressive, multi-faceted, multi-year strategy involving significant leadership from numerous organizational partners at the local and state levels.  It will conduct key informant interviews of local grasstops and grassroots leaders that are working to improve social determinants of health at the neighborhood level, to help test and refine the Alliance concept.  The Alliance will also conduct a rigorous policy and political landscape analysis to identify opportune windows over the coming years, and recommendations on framing and community strategies needed for successful campaigns. 

Project Director: Robert Seifert

“Churning in Massachusetts:  A Planning Study” is a one year project that will examine the feasibility of an updated study of “churning” in Massachusetts’ public health insurance programs, MassHealth and ConnectorCare. Churning is an important phenomenon in public programs because its existence indicates interruptions in health coverage, which often means breaks in continuity of care. The methodology for the planning project will include a literature review and a series of key informant interviews with consumer advocates, state officials, and provider and payer representatives. The information from these activities will then be synthesized into a preliminary research plan for a full study.