Grant Partners

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.

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.

Boston Center for Independent Living (BCIL) will provide services to and seek full integration for individuals with disabilities into society. BCIL will advocate to policymakers and legislative leaders, maintain and strengthen operations for the Disability Advocates Advancing our Healthcare Rights (DAAHR) Coalition, organize the disability community against any threats to coverage or affordability, develop organizational technical expertise, and provide policy analysis and input to the field, particularly related to One Care. BCIL will also increase capacity to focus on behavioral health integration and social equity.

To conduct a feasibility study to collect information for the launch of a Capital Campaign.  The campaign would support upgrades and expansions for the Wellfleet and Harwich Community Health Centers.

To hire a grant writer to develop a fundraising strategy. 

Friends of Jewish Community Housing for the Elderly (JCHE) provides supportive, affordable, independent senior housing in Massachusetts, and owns 1,200 apartments that are home to 1,500 low-income older adults in Brighton, Newton, and Framingham.  In collaboration with the LeadingAge Center for Applied Research, JCHE will seek to demonstrate the effectiveness of affordable housing on the quality of life for the organization's seniors, as well as an impact on costs to the government and health care system.  It will include metro Boston seniors who are low- and moderate-income with similar demographics (income, age, ethnicity, risk profile) living in subsidized housing and receiving supportive services.  The provision of housing will be studied as an intervention at three levels, using Medicaid and Medicare utilization data:  1) housing without services, 2) housing with resident service coordination only, and 3) housing with significant service enrichment. 

Disability Policy Consortium (DPC) will support the civil rights of people with disabilities by providing a unified voice for the community. DPC will promote consumer education and networking, community organizing, grassroots advocacy, policy promotion, and collaborative projects with government and nonprofit entities. It will continue its work with the DAAHR coalition and its Implementation Council, provide cross disability advocacy for access to health care, protect consumer choice and control, influence the implementation of One Care, integrate behavioral health into its work, and prioritize research focused on individuals with disabilities.

To conduct a five-year strategic planning process.

To provide a six-week training course for clinical staff on somatic experiential interventions associated with severe trauma, as well as ten follow-up small group clinical consultations. 

To implement the first phase of Salesforce technology to streamline operations.

People Acting in Community Endeavors (PACE) will facilitate enrollment and redetermination assistance for many “hard to reach” target populations through partnerships with schools, career centers, and ESOL classes. They will also develop materials to help individuals interpret notices and remind them of pending actions, as well as conduct individualized enrollment and group health insurance literacy sessions.

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.

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.

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.

To record and edit audio and visual content for the organization's website that highlights various yoga and meditation practices targeted at women who have been diagnosed with cancer.