Grant Partners

To support the redesign of HLA's website. 

Massachusetts Housing and Shelter Alliance (MHSA) serves unaccompanied homeless adults throughout the state, with a primary focus on the chronically homeless.  MHSA will analyze the impact of housing as a social determinant of health among the chronically homeless population through two permanent supportive housing programs, Home & Healthy for Good and Pay for Success.  In partnership with the Commonwealth Medicine division of UMass Medical School and Analysis Group, the study will estimate the impact of participation in these programs on health care use and costs, using Medicaid claims and enrollment data. 

To produce culturally competent patient education information on vision loss conditions.

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.

To purchase video conferencing equipment.

Ecu-Health Care will utilize broadcast and print media to inform residents of health coverage options; provide presentations to community organizations; educate area businesses about health coverage options for employees; and work with physicians’ groups and health and human service organizations to facilitate referrals. Churn will be reduced through education during one-on-one application assistance appointments and health insurance literacy is integrated into a comprehensive packet for applicants.

To purchase an autoclave for its dental clinic in Worcester.

To support the costs of creating a toolkit to replicate a model of arts-based group therapy sessions.   

The Joint Committee for Children’s Health Care in Everett will provide application assistance and referral support, and conduct a multimedia publicity campaign to reach consumers about the Affordable Care Act.  Additional education will be provided through a multilingual helpline, website, and newsletter.  A series of educational sessions will be conducted at local community organizations on navigating the health system and using the Health Information Exchange.  

CHC of Cape Cod is a patient-centered medical home that has organized its 15,000 patients into primary care teams consisting of physicians, nurse practitioners, nurses, behavioral health counselors, and non-clinical support personnel for the purposes of providing comprehensive integrated care. The health center is implementing a center-wide risk stratification system to identify the most at-risk patients. They are utilizing a combination of national best practices and center-designed tools to identify patients with significant behavioral and medical health co-morbidities, uncontrolled chronic diseases, increased risk for hospitalization, and a history of frequent ED visits. This grant will help support the full implementation of the risk stratification process, and a Complex Care Management program, which a RN has recently been hired to lead. Patients with such indicators as CVD malignancies, positive M3 screens (screens for depression, PTSD, anxiety, bipolar disorder, suicidal thinking, and functionality), a positive SBIRT screen, active drug or alcohol dependency, frequent hospitalizations, difficulty with medication management, and other issues will be treated through the Complex Care Management program. Other patients with lower risk indicators will receive individualized care management from their usual providers and the integration teams, as described above.  Integrated care teams will design care plans with the active involvement of the patient and their family members; progress and follow-up plans will be documented. When a patient with complex behavioral health needs is referred to another community partner (e.g. Gosnold, Bayview, Falmouth Hospital, Cape Cod Behavioral Health), the health center tracks to see if the patient schedules an appointment, and requests a ‘release of information’ to include in the patient’s EHR for better continuity of care. 

Fishing Partnership Health Plan will educate households on the Affordable Care Act, targeting “family health brokers” and community leaders to be navigators in providing frontline education and enrollment assistance.  Seminars and trainings will be offered at shore side processing plants, industry meetings, occupational safety training seminars, and settlement houses, complete with a training curriculum for all navigators.  The “Do You Love a Fisherman?” campaign will be launched with marketing materials, services, and incentives targeting spouses and family members.  

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.

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.

To hire a design firm to revamp its website.

To hire a consultant to provide staff training on trauma.