Attachment A: FY2015 ICB Awardees

Organization Name

Org. Type

Project

Proposal Description

Anna Jaques Hospital

Hospital

A1

Implementing an EMR system and database for the hospital's new cancer center, with a goal of exchanging information with
disease registries and the Mass HIWAY.

379,148

Anna Jaques Hospital

Hospital

C5

Enhancing technology (wireless connectivity, secure messaging, external portal membership) and hardware to enhance
communication between the hospital and their two main vendors for sub acute services.

348,342

C6

Performing a study to identify issues and barriers associated with integrating 5 primary care practices-associated with Anna
Jaques Hospital into the central call system. Goal is to determine if their central call center can be effective in decreasing noshows and improving work flow for scheduling, thereby improving the patient experience. A study will also be done to
determine what resources are needed to have the call center do outreach to those patients not currently receiving the primary
care they need.

19,747

747,238

723,671

723,671

472,750

472,750

136,073

136,073

144,154

Anna Jaques Hospital

Hospital

Anna Jaques Hospital Total

Berkshire Medical Center

Hospital

C1

Creating a Care Management Hub for substance abuse services to address access to and coordination of SUD treatment and
recovery support services through primary and specialty pain care with a strong focus on opioid addiction. It is a fully
integrated approach to treatment and recovery support that embeds expertise in community primary care practices and
creates access to a full range of services needed by those suffering from addiction.

Berkshire Medical Center Total

Beth Israel Deaconess Hospital - Plymouth, Inc.

Hospital

A1

Developing a single electronic health record to be used by BIDMC Plymouth, Milton and Needham through analytics tools
for accessing current electronic health records, and creating of a single order set process for all clinical content as well as
revenue cycle, general ledger and purchasing processes across all affiliates.

Beth Israel Deaconess Hospital - Plymouth, Inc. Total

Beth Israel Deaconess Medical Center d/b/a

Bowdoin Street Health Center

CHC

C1

Implementing and integrating community health workers (CHWs) within each of the three medical home teams at BSHC.
The goal is that the CHWs will coordinate with ongoing team-based care management efforts and assist with patient
navigation, care coordination, culturally tailored education, and social resource connection.

Beth Israel Deaconess Medical Center d/b/aBowdoin Street Health Center Total

Beth Israel Deaconess Medical Center, Inc.

Hospital

A1

Implementing single sign on integration from the ED EHR to the PMP system. Additional system integration tasks involve
automatically populating patient demographic information into the PMP system.

Funding Award

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Beth Israel Deaconess Medical Center, Inc.

Hospital

C2

Decreasing ED utilization for non-traumatic, non-emergent dental conditions at the BIDMC Emergency Medicine
Department. Funds are needed for the development and implementation of an active referral program including an innovative
staff position the emergency dental navigator to manage dental student volunteers who will escort and help underserved
$
patients understand that pain prescriptions are inadequate treatments for non-traumatic dental problems, and appropriate
services with oral health providers are still necessary.

142,129

286,284

315,957

315,957

Beth Israel Deaconess Medical Center, Inc. Total

Boston Health Care for the Homeless Program, Inc.

CHC

Building enhanced organizational integration strategies that link BHCHP and nine Constituent Providers across the
continuum of care, including providers of services from primary care, mental health and substance use services to housing,
English as a Second Language resources, and employment placements to homeless and unstably housed men, women, and
children in Greater Boston. This cross-continuum integration will not only improve the experience of care for homeless
individuals accessing these agencies respective services, but will also poise the team members to be able to collaboratively
address the social determinants of health through MassHealth payment reform initiatives, including Accountable Care
Organizations (ACOs) and/or Health Homes.

Boston Health Care for the Homeless Program, Inc. Total

Brockton Neighborhood Health Center

CHC

A1

Purchasing and installing NextGens Population Health Module, upgrading and enhancing aging hardware, related software,
server environment, and IT security server.

332,045

Brockton Neighborhood Health Center

CHC

Attempting to reach an additional 36,750 potential consumers, producing a projected 10,500 applications and 9,000
enrollments for consumers based on FY15 departmental outcomes during the contract period.

238,514

570,559

Hiring 2 RN Care Coordinators, 2 Social Workers (MSW/LICW), and 3 Medical Assistants and supporting staff supervision and
training as needed to implement Integrated Care Plans, provide Individualized Care Management planning, and track
utilization and effectiveness of all services through the agencys EHR. Goals Include: Reduced emergency room usage;
$
reduced hospitalization and re-hospitalization rates; increased medication adherence; reduced no-show rates related to
clinic visits, referrals, and consults; increased screening; and increased return to work or school among medically complex
patients.

479,923

479,923

39,495

39,495

237,609

Brockton Neighborhood Health Center Total

Caring Health Center Inc.

CHC

C1

Caring Health Center Inc. Total

Charles River Community Health

(formerly Joseph M. Smith Community Health
Center)

CHC

Increasing the capacity of Access to Benefits and Care (ABC) Program to build upon past success of providing outreach and
insurance enrollment assistance to vulnerable and hard to reach populations in Allston-Brighton and Waltham; recent
accomplishments include creation of a risk stratification system and a high-risk patient registry.

Charles River Community Health(formerly Joseph M. Smith Community Health Center) Total

Community Health Center of Cape Cod, Inc.

CHC

C5

Developing a Clinical Integrated Acute and Post-Acute Network Across the Continuum of Care.

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Community Health Center of Cape Cod, Inc.

Community Health Center of Cape Cod, Inc. Total

CHC

C6

Developing a specialized and dedicated practice support center; ICB funding will be used to support hiring 3 full time patientaccess specialists and a triage nurse. Anticipated outcomes include (but are not limited to): 1) At least 85% registered of
patients seen for preventive health visit and/or chronic disease follow up through their primary care provider (within the last $
12 months); 2) 5% reduction in no-show rates within primary care, behavioral health and dental services; 3) Live telephone
phone triage 24/7; 4) Just in Time scheduling protocols-real time matching of appointments to demand for services.

178,680

416,289

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Community Health Center of Franklin County, Inc.

Community Health Center of Franklin County, Inc.

CHC

CHC

C6

Hiring a triage nurse to support patient access to care, provide real-time clinical advice to patients and match demand for
same-day primary care consults. Currently staff functioning in this capacity, in an ad hoc position, is either a receptionist
and/or one of the nurses who may be available and unfortunately, it is often done in a manner that is not tightly integrated
with patient management system.

44,510

Requesting funding to maintain an outreach and enrollment team member whose position is at risk of being eliminated due
to a lack of funding. This person is bilingual, and trained by the Health Connector and MassHealth as a Lead Certified
Application Counselor. This person would expand their current role to track broken appointments to prevent further
instances of no shows, and to be trained as a SHINE counselor to work with the 65+ population in the Franklin/North
Quabbin area.

20,983

65,494

Connecting individuals to health insurance and primary medical care through outreach, marketing, and enrollment activities.
Proposed activities include maintaining partner relationships established through last years project; outreaching to newly
$
identified target populations; and implementing new outreach activities to reach a wider audience including children who
may be eligible for CHIP.

70,097

70,097

Adding a consulting psychiatrist on the Integrated Care Management Program (iCMP) team to advise iCMP staff in the
development of care plans for high-risk patients with co-morbid mental health issues; for Advanced Care Planning education
for PCPs at Northampton Family Practice, Valley Medical Group, and Atkinson Family Practice, as well as five iCMP staff; the
provision of outreach and materials on transportation challenges and opportunities for high-risk patients accessing medical $
care to area staff of primary care providers, VNA/hospice, councils on aging and elder service agencies; for professional
development and certification of the iCMP staff, and the provision of patient tool kits to high risk-patients in support of
disease self-management.

58,202

58,202

Community Health Center of Franklin County, Inc. Total

Community Health Connections

CHC

Community Health Connections Total

Cooley Dickinson Hospital, Inc.

Hospital

C1

Cooley Dickinson Hospital, Inc. Total

Dimock Community Services Corp

CHC

A1

Purchasing and customizing a CCM software application to support further integration at the practice including residential
service.

157,291

Dimock Community Services Corp

CHC

C6

Evaluating wait times for non-urgent appointments in an attempt to reduce backlog and implement a patient-centered, kiosk
and mobile technology driven patient portal which will utilize text messaging strategies and improve the capture of
demographic and contact information as of addressing no-show rates.

107,536

264,827

127,850

Dimock Community Services Corp Total

Edward M. Kennedy Community Health Centre

CHC

A1

Creating dashboards across all specialties and disciplines and purchasing software to assist with reporting and internal data
exchange.

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Edward M. Kennedy Community Health Centre

CHC

Edward M. Kennedy Community Health Centre

CHC

C1

Developing and testing primary care-based complex care management teams at two sites by redefining nursing roles;
restructuring nursing visits and creating new workflows; centralizing visit planning reports; further integrating community
health workers; training CCMs/nurses and CHWs in chronic disease self-management, motivational interviewing, and
integrated care planning; and designing utilization reports for measurement and quality improvement.

394,838

C6

Building an advanced access system to better match the supply of appointments with demand, and streamline and
transform delivery system to be more patient centered and responsive to patient needs. Project includes: 1) studying
appointment demand; 2) reserving a number of appointments for immediate (same or next day) access and another set of
appointments for short term follow up, so that patients will receive care with their primary providers close to the time that
$
they request or need it; and 3) developing scheduling protocols, practices, and scripts. EMKCHC will pilot test the model on a
smaller scale and make revisions before rolling it out across the organization, using a Plan-Do-Study-Act approach, such as
used in LEAN continuous quality improvement programs.

331,684

854,372

62,695

62,695

119,440

119,440

188,777

188,777

616,196

616,196

Edward M. Kennedy Community Health Centre Total

Family Health Center of Worcester, Inc.

CHC

Facilitating access to health insurance programs for uninsured consumers in Greater Worcester area and South Worcester
County by supporting 3.2 FTE Certified Navigators (2.2 at main clinical site in Worcester and 1 at Southbridge clinic). Goal is
to meet growing need for multilingual health benefits advising and enrollment/post-enrollment assistance. Primary
deliverable is to reduce percentage of uninsured patients served by this provider from 15% to 10%.

Family Health Center of Worcester, Inc. Total

Fenway Community Health Center Inc.

CHC

A1

Procuring, installing, and implementing hardware and software that will facilitate the development of a seamless data
analytics and patient level reporting system that will include all aspects of care for patients, including clinical and
administrative data.

Fenway Community Health Center Inc. Total

Franciscan Hospital for Children

Hospital

C4

Improving care transitions for children in behavioral health (BH) or medical rehabilitation to decrease readmission. The
study builds on previously funded work. For BH: tests a new parent survey tool, interviews adolescents regarding factors
related to readmission in the past (suicidality and subjective community transition), examines correlation between
readmission and 3 clinical factors. For MEDICAL: Examines readmissions, develops a key driver and top readmission
diagnosis list, may revise a minimum data set for discharge.

Franciscan Hospital for Children Total

Good Samaritan Medical Center

Good Samaritan Medical Center Total

Hospital

C3

GSMC will build upon its success in Alternative Quality Contracts and the Medicare Pioneer program.

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Greater Lawrence Family Health Center

CHC

Investing in Data Warehousing and Reporting, that will involve the purchase and implementation of new
technology for data analytics, contract and hire personnel with experience and expertise in analytics beyond prior
capacity; and dedicating a GLFHC analyst to re-build reporting capacity based on the new technology

717,083

Greater Lawrence Family Health Center Total

717,083

Greater New Bedford Community Health Center

GNBCHC along with its Constituent Provider Community Counseling of Bristol County are requesting funds to implement
Project A3: Mass HIway Connection and Utilization. The funding will support GNBCHC and CCBC in using the MassHIway for
secure medical record exchange. GNBCHC has established a relationship with CCBC to provide onsite behavioral health
$
services to its patients. Integrating behavioral health services into GNBCHCs primary care approach is critical for quality
care and cost reduction. Effective integration, however, requires that GNBCHC and CCBC communicate seamlessly
regarding patient care.

94,818

94,818

CHC

A2

A3

Greater New Bedford Community Health Center Total

Harbor Health Services, Inc.

(Neponset Health Center)

CHC

A1

Purchasing and installing Care Sentry, which works in concert with NextGen EMR to qualify patients for specific disease
registries and provides real time alerts at the point of care and prompting for important interventions.

147,058

Harbor Health Services, Inc.

(Neponset Health Center)

CHC

Hiring an information technology consulting firm to conduct a comprehensive technical, financial and clinical evaluation of
their current Electronic Health Record (EHR) system in order to achieve improvements to current EMR and IT structure to
position the CHC to participate in alternate payment methodologies and care delivery models.

35,545

182,603

383,887

383,887

Harbor Health Services, Inc.(Neponset Health Center) Total

Harrington Healthcare Systems

Hospital

A1

Replacing the ED information system across both campuses with a fully integrated solution that will streamline workflow
and flow of data throughout the continuum of care, provide data analytic capabilities, and better integrate ED data into
Harringtons population health strategy.

Harrington Healthcare Systems Total

Harvard Street Neighborhood Health Center

Harvard Street Neighborhood Health Center

Harvard Street Neighborhood Health Center Total

CHC

CHC

A1

Implementing a PCMH model and dental EHR module. The center is seeking to hire a director of quality insurance $75000.
The remaining $35000 integration of the centers dental records in to main EHR system.

57,267

C1

Hiring a Chronic Disease Care Coordinator to work with existing staff to develop a primary care-based complex care
management model for high risk patients. A grant implementation team will be created and will consist of the Chief Medical
Officer (CMO), Chief Operations Officer (COO), Director of Quality Assurance, and the new Chronic Disease Care
Coordinator.

41,469

98,736

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Harvard Street Neighborhood Health Center

CHC

Implementing a robust outreach and enrollment initiative to increase awareness of insurance products and care
opportunities through increased staffing.

205,372

205,372

Implementing a population-level analytics project to improve the health of patient populations, improve their
experience of care, and reduce unnecessary costs. Utilizing newly established electronic health record,
eClinicalWorks, to generate and analyze clinical data on patients that utilize high-cost health care services and
$
patients that have frequent hospital readmissions, and working with third-party insurers to access claims reports on
patients at high risk for readmissions and utilization of high cost services. Their Care Management Department will
provide population care management services.

341,832

341,832

Adopting the ADA Standards of Care for Diabetes management and standardizing practices in accordance with the Joint
Commission Standards for disease specific care for those with Type 1 and Type 2 Diabetes. Both hospitals completed a three
year Diabetes Strategic Plan adopted in 2013 to become a Diabetes Center for Excellence. The Plan includes goals in In$
patient diabetes management, out-patient diabetes management, community programs addressing diabetes, and human
resource management to include adoption of a values statement and staffing plan.

175,252

Harvard Street Neighborhood Health Center Total

HealthFirst Family Care Center, Inc.

CHC

A1

HealthFirst Family Care Center, Inc. Total

Heywood Hospital

Heywood Hospital

Hospital

Hospital

C3

C6

Implementing a practice support call center for Heywood Medical Groups 4 primary care locations. Technologies chosen
(eg. patient reminder system) allow better monitoring and addressing issues associated with scheduling and no-show
appointments, so that patient demand matches provider availability. Desired outcomes : Improved patient satisfaction &
efficiencies, cost savings, reduced no-show rates for appointments, and expanded scheduling options for patients.

Heywood Hospital Total

Holy Family Hospital

Hospital

A1

Developing concrete analytic and data-sharing capabilities and resources that directly enable and support integrated and
patient-centered care across providers.

Holy Family Hospital Total

Holyoke Health Center Inc.

Holyoke Health Center Inc. Total

CHC

C6

Upgrading the existing call center, improving communication with patients that have different linguistic needs, and
improving patient continuity. By implementing new software and technologies, HHC aims to identify and reduce the issues
and barriers regarding patient satisfaction and appointment scheduling.

144,440

319,692

796,026

796,026

129,629

129,629

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Island Health Inc.

CHC

A2

Investing in 1) new data warehouse functionality including hardware, data management and architecture, and user-facing
business intelligence, contracting with an external vendor to create a unified, secure warehouse of claims, billing and
information with necessary partitioning and permissions, to support IHCs financial analytics and reporting capabilities and
2) Analytics Capabilities: support financial management and APM, including staff trainings that enhance and expand use of
existing data and analytics capabilities, and either hire new dedicated analytics staff resources or contract with an external
analytics vendor(s).

79,798

Island Health Inc.

CHC

A3

Connecting to the HIway to utilize the Mass HI ways query and retrieve capabilities. This will involve creating an Allscripts
interface to the Mass HIway and implementing an opt in consent process. This is a natural extension of Island Health Cares $
recent implementation of Allscripts electronic health record.

64,000

143,798

48,202

48,202

Island Health Inc. Total

Island Health Inc.

CHC

Conducting outreach and marketing activities; providing information and education; screening, enrolling and/or referring
patients to appropriate programs; and helping applicants and current enrollees to gather and submit all required
verifications and documents. Providing post-enrollment assistance to help enrollees, as well as track, assess and report
causes of no-shows and appointment cancellations and develop a plan to provide assistance to patients to prevent reoccurrences.

Island Health Inc. Total

Lahey Hospital & Medical Center

CHC

A1

Developing a tool within Epic for Hypertension Registry to identify subsets of patients with hypertension and to store the
relevant information to track and analyze the health care needs in a registry that can be shared across the health system. The
anticipated output will be a new hypertension chronic disease and wellness registry that will simplify reporting on patient
subsets and help Lahey act upon its findings.

284,361

Lahey Hospital & Medical Center

CHC

A2

Developing a data warehouse to access and use data across Lahey Health System. The Data Warehouse will allow
physicians to access reports and extract data to identify gaps in assessment, manage patient populations and prioritize
interventions.

441,351

C4

Training 100 physicians, advanced practitioners, and nurse care/case managers to use TouchCare, a web-based
telehealth product, to offer virtual visits to patients asked to schedule a follow-up primary care visit within seven
$
days of a hospital discharge. LHMC expects to increase the show rate among patient follow-up visits from
approximately 38% to 55% across the system, with approximately 10% of those visits being virtual visits, using the
TouchCare product. In the long term, LHMC anticipates a reduction in 30-day readmission rates.

183,170

908,882

Lahey Hospital & Medical Center

Lahey Hospital & Medical Center Total

CHC

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Lowell Community Health Center

CHC

C6

Strengthening the health centers Practice Support Center by improving clinic visit design structure to ensure good patient
flow and further enhance the patient, provider, and staff experience; FY14 ICB grant received to create framework for PSC
and will now leverage technology, use current staff and hire new staff.

419,999

419,999

345,499

345,499

Creating a floating behavioral health team to collaborate with PCPs and offer integrated behavioral health services within 12
PCP offices. LGH will hire 3 social workers who will have both ad hoc and scheduled visits at these sites; this is to address
$
access to BH counseling which may result in decrease and avoiding ED visits.

203,040

203,040

1,137,800

Lowell Community Health Center Total

Lowell General Hospital

Hospital

A2

Working with eClinicalWorks to utilize the ACO adaptor product to capture data from PCP offices and send the data to be
stored in the Athena data warehouse. The ACO Adapter tool is critical to the organization as a whole to perform
commercial and Medicare risk contracts and will enable organizations to enter into new value based contracts.

Lowell General Hospital Total

Lowell General Hospital

Hospital

C1

Lowell General Hospital Total

Lynn Community Health Center

CHC

A1

Supporting major enhancements to the DRVS tool developed and used by 10 CHCs in coordination with the Massachusetts
League of Community Health Centers by the technical product manager Azara HealthCare for expansion of integrated data to
$
provide a) population level analytics, b) Population Disease registries with costs associated from the Total Medical Expense
data and enhanced Provider Dashboards for improved use by providers and to support outcomes driven care.

Lynn Community Health Center

CHC

A2

Enhancing infrastructure and capacity for data analytics, warehousing, and reporting to directly support the health centers
participation in Alternative Payment Methodologies.

185,247

Delivering and enhancing the comprehensive continuum of enrollment services already developed, which includes outreach,
education, enrollment assistance, and post-enrollment services. Planning to improve O&E Program by developing a
$
proactive, population management approach to enrollment utilizing the robust capabilities of new Epic electronic health
record (EHR) and electronic practice management (EPM) systems.

285,369

1,608,416

Lynn Community Health Center

Lynn Community Health Center Total

CHC

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Manet Community Health Center

CHC

A1

Evaluating the current environment and implementing an approved work plan in consultation with Health Management
Associates, with the goal of becoming more prepared for the global environment through enhanced abilities to maximize
$
data retrieval and reporting from Manets EHR, AthenaHealth, and other data systems to improve Manets ability to manage
care, and monitor outcomes and costs.

116,904

116,904

39,356

39,356

154,002

154,002

Reducing non-emergent and inappropriate emergency department (ED) utilization with a goal of improving patients' overall
health and reducing unnecessary costs to the Commonwealth. Mass Health patients are accessing emergency care as a
means to seek treatment for chronic and often complex medical and behavioral health issues. These patients are often
referred to as super-utilizers and account for a significant portion of Mass Health spending annually. Goals include
$
identifying super-utilizers, developing educational materials for community providers and patients, implementing patient
centered care management plans customized to address the needs of patients who routinely use the ED for non-emergent
services, and acting together as an outreach team with the addition of a Licensed Independent Clinical Social Workers
(LICSW) to address patient care in the most appropriate care setting.

309,706

309,706

96,327

Manet Community Health Center Total

Marlborough Hospital

Hospital

C2

To implement project to redirect individuals who visit ED with non-emergent conditions to nearby alternative care sites; to
focus on high ED utilizers & behavioral health patients; to design interventions to reduce non- emergent ED use; to work
with urgent care providers; and to design education/marketing materials for patients and PCPs

Marlborough Hospital Total

Milford Regional Medical Center

Hospital

C1

Collaborating with Arbour Fuller Hospital and Riverside Community Care to implement an integrated system for patients
with behavioral health and substance abuse needs. By collaborating with these two entities, MRMC expects to strengthen
their current multidisciplinary team by improving care through formal and informal assessments and development of
Integrated Care Plans to improve linkages with primary care and community resources.

Milford Regional Medical Center Total

Morton Hospital

Hospital

C2

Morton Hospital Total

North End Community Health Committee, Inc.

CHC

C1

Establishing NEWH substance abuse navigator program to expand primary care/behavioral health integration to substance
abuse treatment and case management by establishing navigators that would expand the reach of clinicians providing
behavioral health/substance abuse services.

CONFIDENTIALITY NOTICE: This document contains information that is privileged, confidential, or otherwise protected from disclosure. Any review, dissemination, or use of this transmission or any of its contents is strictly prohibited.

North End Community Health Committee, Inc.

North End Community Health Committee, Inc.

CHC

CHC

C6

Engaging call center consultants with the goal to access latest technology and call center know-how in order to develop
systems supporting PCMH. Primary goals are increased efficiency, increased patient satisfaction, increased staff satisfaction,
$
and increased coverage (24/7/365). Additionally, this project will enable North End Community Health to handle increased
call volumes resulting from the opening of a new health center location.

261,968

Expanding on last year's initiative to outreach to individuals in need of enrollment and to also focus its work in preventing
gaps of coverage for those who achieved insured status but who face linguistic, literacy, access to-on line services and
$
transportation barriers to processing reapplications. Expand access to Mandarin, Cantonese, and Haitian Creole and Spanish
staff at the high school.

201,224

559,519

96,319

99,049

195,368

Creating a care-coordination call center that leverages new features in the EMR to create a central hub for patient reminder
calls, preventive care reminders, overdue patients and high risk patients through all SCCHC departments. Anticipate that this
project will free clinic support staff to focus solely on patient care and will improve the patient experience. Adding dedicated
staff to conduct all non-clinical and administrative follow-up with patients will free front line reception and support staff to
$
dedicate 100% of their energy to serving the patients directly in the clinic instead of splitting time between outreach and
patient care. Implementing the eClinicalMessenger tool is expected to increase patient compliance with routine care
through automated reminder calls and preventive campaigns and lower the number of no-shows and cancellations.
Centralizing and automating the location for all patient communication including reminder calls and follow-up care.

119,359

119,359

128,989

128,989

North End Community Health Committee, Inc. Total

North Shore Community Health

CHC

C6

Funding to train four existing call center Patient Service Representatives (PSRs) in dental terminology, dental scheduling
practices, types of dental visits and procedures, and utilization of the newly installed dental software, Dentrix Enterprise. In
addition, NSCH will hire a new Patient Access Representative (PAR) to facilitate improved access for patients seeking services $
in all departments. The aim is to decrease no shows/cancellations and to establish procedures to mitigate call center
backlog.

North Shore Community Health

CHC

Expanding on last year's funding to focus on post-enrollment support, educating applicants about how to use the enrollees
health insurance benefits and access services they need; conducting follow-up to ensure engagement with PCP and
enhancing outreach and enrollment infrastructure and post-enrollment assistance and education.

North Shore Community Health Total

South Cove Community Health Center

CHC

C6

South Cove Community Health Center Total

South End Community Health Center

South End Community Health Center Total

CHC

Hiring: 1.0 FTE staff who will augment current outreach and insurance enrollment activities and serve as a liaison between
Community Programs and the Insurance Coordination team; 1.0 FTE Patient Navigator, and 0.5 FTE Nurse Care Manager.
These last two positions will serve as concierges for new patients to help reduce barriers to understanding healthcare
services , liaise with clinical departments and ancillary services, and help educate patients about insurance plans and
coverage.

CONFIDENTIALITY NOTICE: This document contains information that is privileged, confidential, or otherwise protected from disclosure. Any review, dissemination, or use of this transmission or any of its contents is strictly prohibited.

South Shore Hospital

Hospital

Reducing non-emergency visits by Manet patients to the hospital ED by 40% and increasing CHC patient access to primary
care and coordinated services. Crux of the program is a team of social workers co-located in the hospitals ED. The goal is to $
improve quality of care and generate cost savings.

320,548

320,548

1,668,229

1,668,229

35,545

35,545

A1

Acquiring an HIE in order to facilitate care coordination across all providers and to support population health efforts. All
patient data will be incorporated into the HIE, regardless of payer. This information can be stored in a lifetime health record
$
of data from across providers or can be sent upon request of a provider to another provider. Connecting two additional EMR
systems to the NEQCA/Tufts Medical Center Provider registry to support quality measure reporting.

301,673

C4

Enhancing infrastructure for preventing unnecessary readmissions. To address the challenge of high readmission rates, by
supporting improvements that build capacity to identify patients at high-risk for readmission and to help deploy targeted
interventions to improve their transition from an acute care setting. Developing a multi-stakeholder cross-continuum
transition team.

339,828

641,501

512,923

512,923

C2

South Shore Hospital Total

St. Elizabeth's Medical Center

Hospital

Enhancing organizational integration and collaboration among partner entities in preparation to implement a Medicaid accountable
care model. Steward seeks to leverage resources to partner with community-based providers and to strengthen capabilities among
service areas with high Medicaid need, including outpatient behavioral health and services that support social determinants of health.

St. Elizabeth's Medical Center Total

Stanley Street Treatment and Resources, Inc.

CHC

Expanding Health Access Team beyond the service scope of the health center and focusing on three specific populations, (1
& 2) the growing Hispanic and Brazilian populations in the Greater Fall River area seeking assistance in navigating the
Massachusetts Health Connector system with an interpreter of their language of choice and (3) the homeless population
that is required to have health insurance when seeking mental and physical health care. Goals are to provide 25 outreach
activities, to reach 7,500 consumers, to submit 170 applications, to complete 270 enrollments and to assist 150 consumers
with redeterminations in six months.

Stanley Street Treatment and Resources, Inc. Total

Tufts Medical Center

Tufts Medical Center

Hospital

Hospital

Tufts Medical Center Total

UMass Memorial Medical Center, Inc.

UMass Memorial Medical Center, Inc. Total

Hospital

A2

Supporting the assessment, planning, development and implementation of a population health data aggregator through
investment in the infrastructure necessary to do a complete strategic evaluation of the currently available aggregator
solutions in the market as well as to ensure compatibility with their strategic vision for an Accountable Care Organization.
The aggregator will help to create a more complete longitudinal record and will help define populations of patients that
could most benefit from care management interventions.

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UMass Memorial Medical Center, Inc.

UMass Memorial Medical Center, Inc.

UMass Memorial Medical Center, Inc.

UMass Memorial Medical Center, Inc.

Hospital

Hospital

Hospital

Hospital

C1

Expanding care management within the UMass ACO & Ambulatory Care Management team created to work with ACO
beneficiaries across the continuum of care through home visits, telephone contact, and provider office visits. Goals include
working with beneficiaries from 5 primary care teams with complex high-risk needs and beneficiaries from ACO participants
who demonstrate high utilization patterns. Project proposes to expand the UMass. ACO care management team & meet the $
needs of an additional group of several thousand more beneficiaries. Also, since identifying patient activity is a key factor in
managing care across the spectrum, the ACO team is working to adopt a web-based tool which provides notifications from
various provider types about patient activity in both the local community & across the country.

182,369

C1

Expanding on the UMass ACO care management team to meet the care management needs of an additional 15,000+
Medicare beneficiaries from 57 corporate entities who will be newly attributed in calendar year 2016 to the UMass
Memorial ACO. Additionally, over 750 Medicare Medicaid dually eligible beneficiaries from Fallon Total Care / One Care
program will be attributed to Umass ACO beginning in January 2016. These two groups will represent approximately 4,200
additional high risk lives for longitudinal management. The ACO Care Management team is working to adopt PatientPing, a
secure web-based tool which provides notifications from Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs),
Long Term Acute Care, Rehabilitation and Acute Care Hospitals to risk-bearing entities, such as ACOs, about patient activity
in the local community and across the country.

221,204

C2

Identifying patient population that utilizes ED for non-emergency conditions and designing an intervention to reduce nonemergent ED use. Anticipated Outcomes include: a database that supports analytics and regular reporting on patients with
non-emergency ED use; an analysis of characteristics of these patients and their patterns of healthcare utilization to guide
intervention development efforts; technology tools that enable identification of frequent non-emergency ED use and
participation in care coordination efforts; and a new, pilot-tested intervention to reduce non-emergency ED use that
capitalizes on infrastructure built as part of the grant.

297,470

C4

Developing several interventions that will increase the likelihood of continued success post-discharge. Specifically, this
would include 1) the development of a recovery coach program begins during the hospitalization and continues up to three
months post discharge and 2) the initiation of pharmacological treatments in the general hospital that are linked to
coordinated outpatient programs using suboxone, naltrexone and other medications targeted at substance use disorders.

184,186

885,229

53,484

UMass Memorial Medical Center, Inc. Total

Upham's Corner Health Committee, Inc.

CHC

A2

Hiring a data analyst to focus on analyzing the data the health center receives from various insurance carriers by monitoring
the data received from insurers and other funders to produce more streamlined processes and reporting.

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Upham's Corner Health Committee, Inc.

CHC

C6

Researching how other community health centers reduce their do not keep appointment rate to test different methods
over the 6 month period of the contract. The anticipated outcome is identifying a method that most effectively reduces the
do not keep appointment rate. Currently, the automated appointment reminder system Televox is used to call and remind $
patients of appointments. However, the health center would like to explore using the Televox system for text reminders and
see if such technology has an impact on the no show rate.

5,690

59,174

Upham's Corner Health Committee, Inc. Total

Whittier Street Health Center

Whittier Street Health Center

Whittier Street Health Center

Whittier Street Health Center

Whittier Street Health Center Total

CHC

CHC

CHC

CHC

A1

Implementing of Electronic Dental software and Electronic Lab software to interface with new Whittier Electronic
Health Record (EHR), to provide coordinated care and easily share patient information across the continuum of
care.

156,475

C1

Addressing the opioid crisis in the inner city Boston service area, by implementing a Primary Care Based System of
Complex Care Management for the High Risk Population of Substance Abusers with Opioid Dependence. Whittier Street
HC will expand and enhance a multidisciplinary team-based framework for individuals with opioid dependence, utilizing
their integrated primary care/behavioral health team and their new Integrated Nurse Care Manager will develop and
implement reports to track the utilization and effectiveness of Whittiers Primary Care-based Care Management of opioid
dependent patients.

348,944

C6

Establishing a Call Center to improve patients total experience as they navigate the system and interact with staff at all
levels through organizational changes and capacity building and strengthening existing Care Coordination program by redefining clinical supports staff's roles and responsibilities in supporting providers and patients. The patient population will be $
stratified to different risk levels (high, moderate and low risk, based on their health and social issues), and a team of support
staff will be assigned to each risk level to assist the providers in caring for the patients in each population.

191,249

Designing and implementing a project supporting enrollment in public subsidized and non-subsidized health insurance for
residents of the 5 Boston Housing Authority (BHA) public housing developments directly surrounding Whittier. Whittier will
hire one bilingual (Spanish/English) Financial Counselor who is a Certified Applications Counselor (CAC) to work with the five
Social Health Coordinators at the 5 local housing developments, to help residents learn about their insurance options, to
remove barriers such as insufficient documentation, and to enroll them in insurance plans.

121,125

817,794

20,000,000

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