Grant Partners

With support from the Foundation, EBNHC will focus on expanding behavioral health services for children and adolescents (ages 5 to 21) who are seen in Pediatrics, Family Medicine and the health center’s School-Based Health Center.  In 2014, the Pediatric and Family Medicine Departments served a total of 15,498 patients up to age 21, and the number of child and adolescent patients served continues to increase.  EBNHC's two newly hired child/adolescent psychiatrists will be able to fully treat and manage, and track and measure, the care of children and adolescents with mild to moderately severe depression and anxiety disorder, and integrate this care with a range of medical conditions.  EBNHC has historically only been able to refer pediatric patients with behavioral health issues to community providers where there are challenges associated with long wait times due to psychiatric provider shortages, as well as geographic and linguistic barriers.  Expanding on-site psychiatric capacity also will help to facilitate care planning for patients following psychiatric hospital discharge.

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.

LCHC has developed and implemented a fully integrated primary care and behavioral health program with co-location of services, co-management of patients by the medical and behavioral health providers through a shared care model, and utilization of shared electronic medical records through a newly-implemented Epic system.  The Foundation has supported the development, growth and improvement of this very strong behavioral health integration program, with continued funding for the health center’s response to the substance abuse epidemic in Lynn.  Building upon the learning and successes of its foundational behavioral health integration model, LCHC has developed an integrated primary care/mental health/addictions team of professionals who specialize in addictions and mental health disorders.  The team also utilizes medication to treat addictions, including Suboxone, with plans to add Vivitrol.  LCHC will expand this multi-disciplinary team by adding a psychiatrist, therapists, primary care providers, and nursing staff to serve approximately 800 patients.

Vinfen has developed 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 CBHH model achieves close collaboration approaching an integrated practice by embedding Nurse Practitioners (NPs), Nurses (RNs) and Health Outreach Workers (HOWs) into existing community-based rehabilitation and recovery behavioral health teams, bringing primary care services directly to individuals with serious mental illness in their communities since 2012.  Over the past three years, Vinfen has been actively evaluating and piloting health technologies in an effort to integrate behavioral and primary health care for its population.  The Foundation-supported expansion program embeds two HOWs and the use of a smartphone app specifically designed to support the population into a dispersed, community-based outreach team.  A dedicated Program Coordinator will manage the program, collect data and evaluate impact.

BCMHC's Healthy Lives program, created in 2011, is designed to increase primary care and behavioral health access for patients with co-occurring serious mental illness and multiple chronic conditions.  The patient-centered model leverages intensive care management strategies to improve access, integrates care, and helps reduce barriers to treatment for patients with complex needs.  In addition to operating a community-based care management model – including home visits, and individual and group counseling – the program introduces self-care and wellness activities for patients to become increasingly more engaged in their own health.  Healthy Lives, which received Foundation grant funding in 2015, serves low-income seriously mentally ill adults living in Brookline, Roxbury, Brighton, Allston, and most recently Dorchester and Mattapan, with at least two chronic medical conditions (such as diabetes, cardiovascular disease or COPD).  Work to date has shown that Healthy Lives significantly improves health outcomes and reduces avoidable ED visits for participants. The goal is to serve 250 to 300 patients over three years.

With support from the Foundation, EBNHC will focus on expanding behavioral health services for children and adolescents (ages 5 to 21) who are seen in Pediatrics, Family Medicine and the health center’s School-Based Health Center.  In 2014, the Pediatric and Family Medicine Departments served a total of 15,498 patients up to age 21, and the number of child and adolescent patients served continues to increase.  EBNHC's two newly hired child/adolescent psychiatrists will be able to fully treat and manage, and track and measure, the care of children and adolescents with mild to moderately severe depression and anxiety disorder, and integrate this care with a range of medical conditions.  EBNHC has historically only been able to refer pediatric patients with behavioral health issues to community providers where there are challenges associated with long wait times due to psychiatric provider shortages, as well as geographic and linguistic barriers.  Expanding on-site psychiatric capacity also will help to facilitate care planning for patients following psychiatric hospital discharge.

Since 2012, Lahey Health Division of Primary Care and Lahey Health Behavioral Services have collaborated to embed behavioral health clinicians in five community primary care practices, sharing medical records, and using the Collaborative Care Model (CCM), a team decision-making model of care.  Through this grant, Lahey Health Behavioral Services proposes a multi-faceted, multi-site expansion of its integrated CCM approach, by adding two community primary care practices (Gloucester and Beverly); introducing CCM in one Lahey Health System obstetrics practice; establishing CCM in one Lahey Health System pediatrics practice; piloting reverse integration at the Lahey Health Behavioral Services community mental health center in Salem; and expanding screenings of primary care patients across all of these sites to identify higher-risk patients and track outcomes.  Lahey Health Behavioral Services will also use tele-psychiatry to enable consulting psychiatrists to serve more patients, particularly for more rural, isolated sites, such as Gloucester, where there is a lack of access to specialty services.

The PPOC launched its Behavioral Health Integration program in 2012 and now has 41 practices participating.  The focus of this initiative is to provide substance abuse prevention and treatment services to adolescents and young adults (up to age 25) and their families at PPOC practices in Lowell and Wareham.  This funding will help expand PPOC’s effort to help practices with high-risk populations detect, treat, and manage substance abuse issues, and make referrals to community-based substance abuse care when needed.  The expansion will enhance the learning community curriculum to offer five additional hours of training on substance use, and ensure that the collaborative behavioral health integration teams have an embedded integration and clinical support specialist with substance abuse expertise via the PPOC's partnership with the Adolescent Substance Abuse Program (ASAP) at Boson Children’s Hospital.

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.

The Department of Family Medicine and Community Health (FMCH), operates primary care practices in which Family Medicine residents are trained alongside clinical health psychology trainees. The development of the integrated behavioral health curriculum and clinical practice has been guided by Alexander Blount, EdD, a nationally recognized leader in advancing integrated primary care. The Center for Integrated Primary Care (CIPC), which he established and runs, is a resource that most of the applicants for this grant have utilized for training their team members. This grant supports integrated care in two of the three family practice residency sites – Hahnemann Family Health Center in Worcester and Barre Family Health Center in the East Quabbin region – and the efforts to use data to assess and improve the role of behavioral health in these practices. Both clinics screen for depression using the PHQ-9, as well as a ten item audit for screening for anxiety, PTSD and physical pain.  The centers have had behavioral health clinicians practicing in the clinics for the past 20 years. In the past four years, these practices have coalesced into more organized integrated models that are leveraging their co-located services to deliver patient-centered care.  Each center has NCQA recognition as Level 3 Patient Centered Medical Homes, and both are participants in the state’s Primary Care Payment Reform Initiative (PCPR).

Healthy Lives:  Brookline Community Mental Health Center will serve 200 low-income adults living in Brookline or Boston who present with serious mental illness (schizophrenia, bipolar disorder, major depression, severe anxiety, or PTSD) and at least two chronic medical conditions (including diabetes, cardiovascular disease, or COPD).  The health center will engage patients in their care, help them coordinate the services they receive, provide wellness interventions, offer disease management programs, home visits, and individual and group counseling. The intent of the project is to help patients move from passive recipients to active participants in their health care and by doing so, reduce cost and improve quality.

Dimock’s approach to delivering integrated care is to focus on interventions designed for specific patient segments – pediatrics, adult medicine, and OB/GYN. Integrated care practices are at different levels of maturity, with pediatric integration having begun in 2011, adult medicine in 2012, and OB/GYN in October 2013. The health center has more 14,000 patients, and expansion of integrated care to adult medicine and OB/GYN marks the launch of routine screening for depression of all patients with the PHQ-9 instrument. As part of universal prevention protocols, patients with no initial behavioral health symptoms will have periodic screenings during medical appointments. Those at risk will receive appropriate behavioral health approaches through co-management with primary care providers (PCPs) and resource coordinators (RCs). Others will require basic interventions, such as peer specialist-led groups for brief episodic interventions from the behavioral health team. Those patients with a mental health disorder will receive treatment from the full behavioral health team (Medical Social Worker, psychiatrist, therapist, and/or substance use clinicians), in partnership with PCPs and RCs. The integrated team will coordinate care with external specialists for patients with severe mental illness who require subspecialty, intensive or home-based care.