Grant Partners

Visiting Nurse Association of Greater Lowell will deliver home health care services, self-care education and coaching, and tele-monitoring to high-cost patients identified by the Lowell General Physician Hospital Organization (PHO) and Lowell Community Health Center. The project will serve 100 “high utilizers” in its first year and will triple in size by its third year. Targeted patients will be those diagnosed with congestive heart failure, chronic obstructive pulmonary disease, or diabetes. In-home assessment, coaching, and monitoring will be provided to patients who do not qualify for these services under current payment and benefit guidelines because they are not homebound and do not have acute, but rather chronic conditions. The project’s goal is to demonstrate the cost-effectiveness of these services.

Mercy Medical Center’s Health Care for the Homeless program (Mercy HCH) will collaborate with hospital emergency departments in Hampden, Hampshire, and Franklin counties to “re-direct” homeless persons who are “high-end utilizers” of emergency department services to access health care services through Mercy HCH’s clinical team.  Mercy knows the area’s homeless well and has documented cases where individuals are going to emergency rooms more than 20 times per month. Mercy HCH staff will work with these homeless individuals to obtain stable housing and resolve chronic conditions such as substance abuse and mental health issues.  Over the three-year grant period, the five participating hospital emergency departments will “re-direct” 120 homeless individuals to more appropriate care through the program.

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.