Grant Partners

A Collaborative Practice Model for Improving Pediatric Mental Health Value:  The Alliance Foundation for Community Health will develop a new method of identifying youth at risk for low quality/high cost mental health treatment. The sample for this study will be drawn from the 101,000 youth under age 20 insured by Network Health. The project will also look within diagnosis groups to compare treatments and expenditures across race/ethnicity, language, geography, and other characteristics. In the second phase of the effort, the project will identify primary care providers who have the largest number of high-expenditure youth and work with them and families to develop more cost-effective approaches to treatment.

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.

The Boston Center for Independent Living (BCIL) will support advocacy on behalf of those living with disabilities.  BCIL is a frontline civil rights organization led by people with disabilities that advocates for supports and services that enhance the independence of people with disabilities.

Massachusetts League of Community Health Centers will serve as a key resource to its membership as cost containment and payment reform continue to reshape the health care environment. The League will conduct a multi-tiered advocacy strategy on a statewide level, including analyzing and disseminating policy information, engaging its members on key issues, and collaborating with other organizations and coalitions that share community health and primary health care goals.

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.

Community Health Connections will provide street outreach and one-on-one application and enrollment assistance to homeless or high risk children and adults, as well as members of the Spanish- and Portuguese-speaking communities.

Ecu-Health Care will provide public health outreach, application assistance, and support for accessing primary care providers. One-on-one training will educate clients on the individual mandate, minimum creditable coverage policies, and affordability regulations.

MyLink:  Community Healthlink and its hospital partners will identify 300 “high user” patients and provide them with a MyLink community support worker who will meet them in the emergency room, maintain regular telephone and in-home contact, provide assistance in meeting basic needs, help anticipate crises, and connect the patient with the appropriate level of care (primary care, home health services, or behavioral healthcare). The project expects to expand to Health Alliance Hospital in Leominster and St. Vincent Hospital in Worcester, and collaborate with dispatchers and EMTs to provide additional insight into the needs of the patients they treat and transport.