Grant Partners

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.  

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. 

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.

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. 

Steppingstone, Inc. will partner with Stanley Street Treatment and Resources (SSTAR) to create a new program called MyCare, an effort to promote a more pro-active approach to health care for those in Steppingstone’s residential recovery programs. The target population for MyCare is persons in early recovery from chronic substance abuse and mental health disorders.  Over 70% of this population has recent histories of homelessness and more than 70% have chronic conditions, in addition to their substance abuse or mental health disorders. The project will begin with residents of its Fall River women’s program in year one and will incorporate the Fall River men’s program in the second year, and its Stone Residence for chronically homeless individuals in the third year. The program projects to serve 465 clients over the three years with one-on-one assistance and intervention. 

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.