Grant Partners

To purchase netbooks and mobile Wi-Fi hotspots for clinicians and case managers to use the Efforts to Outcomes software while treating clients in the field.  

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. 

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.  

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.  

In their project “Analysis of the Massachusetts All-Payer Claims Database to Describe the Epidemiology of Readmissions,” the research team will use the Massachusetts All-Payer Claims Database (APCD) to better understand patterns of hospital readmissions in Massachusetts. Most research on readmissions has been conducted using Medicare data or on data sets that describe only inpatient hospital encounters. By using the APCD, this research will shed new light on the diagnoses and patterns of care associated with readmissions in Massachusetts for all populations. This analysis could help providers develop and focus work around preventing avoidable readmissions.

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.

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. 

To hire a strategic planning consultant.

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. 

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.

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.

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.  

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.  

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.