Grant Partners

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.  

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.

Lynn Community Health Center will develop and evaluate its Integrated Care Project, an effort that integrates primary care and behavioral health care.  It will also develop a universal care plan supported by an electronic health record.  The project will create new models of care management and coordination for the health center’s highest-risk patients.  The health center believes that more appropriate services and increased treatment compliance will result in fewer emergency room visits and inpatient hospital care, reducing overall health care costs.  Over the three-year project, the health center will target 1,000 patients who have the highest rates of emergency room visits and inpatient hospital care.  To serve these patients, Lynn will develop an intensive care management team in which primary and behavioral health providers will work together. 

Enhancing Patient Access to Primary Care:  Greater Lawrence Family Health Center will target “super-utilizers” of the emergency departments of Holy Family Hospital, Lawrence General Hospital and Merrimack Hospital.  “Super-utilizers” are identified as those who have visited the emergency department during clinical hours of operations, could have waited at least 12 hours to be seen, and have been seen at least four times within a 12-month period at one of the hospitals.  A team consisting of a family physician, a behavioral health psychologist, a nurse care manager, and bilingual and bicultural health care coaches will develop care plans for these patients. 

Boston Medical Center (BMC) will integrate a depression-screning tool into the Re-Engineered Discharge (RED) protocol, an 11-step process for reducing the risk of patients being readmitted to the hospital.  Results have shown that patients who receive RED are 30% less likely to be readmitted within 30 days of discharge.  Because further research has shown that patients with symptoms of depression are 74% more likely than those without to be readmitted in this same 30-day window, RED-Plus, as the enhanced intervention will be known, will be piloted on BMC's inpatient services for Boston Medical Center HealthNet patients, whose primary care providers are located in the 15 community health centers affiliated with BMC. 

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.  

Massachusetts Public Health Association (MPHA) will focus on community health integration and improving the built environment. MPHA will work with the Alliance for Community Health Integration to ensure that social determinants of health are adequately addressed, in particular through community investments, support for ACOs from MassHealth, and health care institutions’ internal policies.

Massachusetts Senior Action Council will advocate for health care access for the over 65 population.  It will advocate for its constituents around growing out-of-pocket costs and affordability, expanding access to community-based long-term care by eliminating disparities in eligibility for personal care attendant services, and ensuring adequate funding for home care.  Finally, the organization will increase awareness of and streamline enrollment for existing senior health care programs.

County of Dukes County will provide enrollment assistance at local community organizations to assist consumers in setting up Health Information Exchange accounts, completing applications, checking statuses and making updates.  They will also develop and disseminate information on the Affordable Care Act, with a focus on immigrants and tribal members.  Finally, social media, paid and free media will be used to reach members of the general public on health coverage options.  

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.

Judge Baker Children's Center (JBCC) will implement the Modular Approach to Therapy for Children (MATCH) in four outpatient clinics in the Greater Boston area as a step toward bringing the model to scale in Massachusetts.  In addition, JBCC will compare the costs of treatment using MATCH with typical treatment costs at the participating sites.  MATCH will be utilized to treat children with multiple complex disorders, including some combination of anxiety, depression, post-traumatic stress, and disruptive conduct, including the problems associated with attention deficit-hyperactivity disorder.  Treatment Response Assessment for Children (TRAC) will be used as an outcome measurement system that guides clinicians through the implementation of MATCH.  

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.  

Boston Public Health Commission will assist consumers in enrolling in and selecting health plans, as well as retaining coverage.  They will develop quick-guides on the new marketplace application and renewal processes, and disseminate “Health Portfolios” to consumers to track health coverage, primary care providers, and Affordable Care Act information.  “Roving Navigators” will promote access to health coverage at barbershops, auto body shops, and nail salons.

Caring Health Center will target refugees, immigrants, and other linguistic and cultural minority groups who face barriers to enrollment and health care navigation. The health center provides comprehensive primary medical care and dental services to residents in the medically underserved city of Springfield and its surrounding areas.

Holyoke Health Center will serve 300 patients at high-risk for preventable hospitalization, re-hospitalization, unnecessary emergency department visits, or adverse drug events due to diabetes. The project will begin with identifying patients with diabetes with an unnecessary emergency room visit and recent hospitalization at Holyoke Medical Center, or eight or more prescriptions for diabetes.  A partnership with the Massachusetts Medicaid program will identify high-cost patients and work to understand how to predict which are amenable to disease management programs, leading to more effective, lower-cost services.