Grant Partners

Inpatient admissions that originate in the emergency department (ED) result in a significant portion of total health care spending each year, yet there is both wide variation in admission patterns and little understanding of best practices for post-ED care management and potential cost savings. In their project “Identifying Best Practices to Reduce Hospital Admission from the Emergency Department,” the research team will complete an in-depth study of three common conditions leading to admissions from the ED. By analyzing top-performing hospitals, the researchers will develop strategies and best practices around improving care and reducing costs.

Brockton Neighborhood Health Center will enroll consumers in coverage and assist with renewal applications, and provide education on the Affordable Care Act.  Community leaders from religious, cultural, and human service organizations will be convened and educated on health insurance information and available resources.

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. 

Boston Center for Independent Living will continue to co-lead the Disability Advocates Advancing our Healthcare Rights (DAAHR) Coalition with the Disability Policy Consortium.  The organization will educate policymakers and legislative leaders, maintain and strengthen DAAHR, organize the disability community, develop organizational technical expertise, and provide policy analysis and input to the field, particularly related to the Duals Demonstration Project, known as One Care.

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.  

Codman Square Health Center will conduct outreach and enrollment, hold a series of events to help attendees complete insurance applications, and provide orientations on available health coverage options.  Computers will be made available at the Codman Tech Center to access the health insurance marketplace, and consumers will be connected to the health center’s patient-centered medical home model to promote consumer engagement and self-sufficiency.  

The research team will use the APCD in their project titled “Understanding High-Cost Patients in Massachusetts” to provide in-depth analysis of the small percentage of patients who consume a disproportionately large share of health care spending in the state. By gaining a more detailed understanding of high-cost patients—their diagnoses, co-morbidities, demographic factors, and providers—the researchers hope to help inform the development and targeting of potential cost containment policies, practices, and payment models for Massachusetts.

County of Dukes County will provide enrollment assistance at local community organizations to assist consumers in setting up Health Information Exchange accounts, completing applications, checking statuses and making updates.  They will also develop and disseminate information on the Affordable Care Act, with a focus on immigrants and tribal members.  Finally, social media, paid and free media will be used to reach members of the general public on health coverage options.  

Holyoke Health Center will serve 300 patients at high-risk for preventable hospitalization, re-hospitalization, unnecessary emergency department visits, or adverse drug events due to diabetes. The project will begin with identifying patients with diabetes with an unnecessary emergency room visit and recent hospitalization at Holyoke Medical Center, or eight or more prescriptions for diabetes.  A partnership with the Massachusetts Medicaid program will identify high-cost patients and work to understand how to predict which are amenable to disease management programs, leading to more effective, lower-cost services.

Massachusetts Public Health Association (MPHA) will focus on community health integration and improving the built environment. MPHA will work with the Alliance for Community Health Integration to ensure that social determinants of health are adequately addressed, in particular through community investments, support for ACOs from MassHealth, and health care institutions’ internal policies.

Health Care For All will continue its advocacy agenda to ensure comprehensive health care and coverage for consumers during the implementation of the Affordable Care Act.  The organization will support and monitor the transition for the newly eligible, uninsured and underinsured populations between health plans as the federal and state laws are reconciled.  Finally, it will continue its leadership of various coalitions, including the Campaign for Better Care, Oral Health Advocacy Task Force, and the Affordable Care Today (ACT!!) Coalition to ensure legislative and community support for consumer-centered policy recommendations.

Greater Boston Interfaith Organization will continue its strategic advocacy agenda focused on health care cost containment, monitoring Chapter 224 implementation, and mobilizing its membership in developing a “train-the-trainer” model.  The organization will develop articulated policy positions and principles in holding public and private stakeholders accountable for results, while negotiating with key stakeholders around consumer interests in mitigating rising health care costs.

To develop, print and distribute health education materials.  

Community Action Committee of Cape Cod & Islands will continue individualized “Access to Care – Navigating the Massachusetts Health Care System” educational sessions for consumers, and design a training guide identifying MassHealth mailings and navigating the complex health care system.  They will conduct a series of outreach events to educate the public on changes through the Affordable Care Act.  

Community Health Center of Franklin County will provide a continuum of eligibility, enrollment and review services, resource referrals to primary care, and case management.  They will educate consumers on how to navigate health coverage and care systems through computer access, including the Health Information Exchange.  Educational materials will be developed for patients to take a more active role in their health coverage and care.