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Attachment A: FY2015 ICB Awardees

Organization Name

Org. Type

Project

Proposal Description

 

Funding Award

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

Anna Jaques Hospital

Hospital

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 no- shows 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

Anna Jaques Hospital Total

     

$

747,238

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.

$

723,671

Berkshire Medical Center Total

     

$

723,671

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.

$

472,750

Beth Israel Deaconess Hospital - Plymouth, Inc. Total

   

$

472,750

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.

$

136,073

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

 

$

136,073

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.

$

144,154

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.

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

Beth Israel Deaconess Medical Center, Inc. Total

     

$ 286,284

     

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

 

Boston Health Care for the Homeless Program, Inc.

CHC

B

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.

$ 315,957

Boston Health Care for the Homeless Program, Inc. Total

   

$ 315,957

Brockton Neighborhood Health Center

CHC

A1

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

$ 332,045

Brockton Neighborhood Health Center

CHC

D

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

Brockton Neighborhood Health Center Total

     

$ 570,559

Caring Health Center Inc.

CHC

C1

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 agency’s 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

Caring Health Center Inc. Total

     

$ 479,923

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

   

Increasing the capacity of Access to Benefits and Care (ABC) Program to build upon past success of providing outreach and

 

CHC

D

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.

$ 39,495

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

$ 39,495

Community Health Center of Cape Cod, Inc.

CHC

C5

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

$ 237,609

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.

Community Health Center of Cape Cod, Inc.

CHC

C6

Developing a specialized and dedicated practice support center; ICB funding will be used to support hiring 3 full time patient- access 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

Community Health Center of Cape Cod, Inc. Total

     

$ 416,289

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.

Community Health Center of Franklin County, Inc.

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

 

Community Health Center of Franklin County, Inc.

CHC

D

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

Community Health Center of Franklin County, Inc. Total

   

$ 65,494

     

Connecting individuals to health insurance and primary medical care through outreach, marketing, and enrollment activities.

 

Community Health Connections

CHC

D

Proposed activities include maintaining partner relationships established through last year’s 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

Community Health Connections Total

     

$ 70,097

Cooley Dickinson Hospital, Inc.

Hospital

C1

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

Cooley Dickinson Hospital, Inc. Total

     

$ 58,202

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

Dimock Community Services Corp Total

     

$ 264,827

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.

$ 127,850

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.

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

Edward M. Kennedy Community Health Centre

CHC

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

Edward M. Kennedy Community Health Centre Total

   

$ 854,372

     

Facilitating access to health insurance programs for uninsured consumers in Greater Worcester area and South Worcester

 

Family Health Center of Worcester, Inc.

CHC

D

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%.

$ 62,695

Family Health Center of Worcester, Inc. Total

     

$ 62,695

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.

$ 119,440

Fenway Community Health Center Inc. Total

     

$ 119,440

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.

$ 188,777

Franciscan Hospital for Children Total

     

$ 188,777

Good Samaritan Medical Center

Hospital

C3

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

$ 616,196

Good Samaritan Medical Center Total

     

$ 616,196

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.

Greater Lawrence Family Health Center

CHC

A2

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

     

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

Greater New Bedford Community Health Center

CHC

A3

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 GNBCHC’s primary care approach is critical for quality

$ 94,818

care and cost reduction. Effective integration, however, requires that GNBCHC and CCBC communicate seamlessly regarding patient care.

Greater New Bedford Community Health Center Total

   

$ 94,818

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

     

Hiring an information technology consulting firm to conduct a comprehensive technical, financial and clinical evaluation of

 

Harbor Health Services, Inc. (Neponset Health Center)

CHC

E

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

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

   

$ 182,603

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 Harrington’s population health strategy.

$ 383,887

Harrington Healthcare Systems Total

     

$ 383,887

Harvard Street Neighborhood Health Center

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 center’s dental records in to main EHR system.

$ 57,267

Harvard Street Neighborhood Health Center

CHC

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

Harvard Street Neighborhood Health Center Total

     

$ 98,736

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.

Harvard Street Neighborhood Health Center

CHC

D

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

$ 205,372

Harvard Street Neighborhood Health Center Total

     

$ 205,372

HealthFirst Family Care Center, Inc.

CHC

A1

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

HealthFirst Family Care Center, Inc. Total

     

$ 341,832

Heywood Hospital

Hospital

C3

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

Heywood Hospital

Hospital

C6

Implementing a practice support call center for Heywood Medical Group’s 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.

$ 144,440

Heywood Hospital Total

     

$ 319,692

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.

$ 796,026

Holy Family Hospital Total

     

$ 796,026

Holyoke Health Center Inc.

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.

$ 129,629

Holyoke Health Center Inc. Total

     

$ 129,629

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.

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 IHC’s 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

     

Connecting to the HIway to utilize the Mass HI way’s query and retrieve capabilities. This will involve creating an Allscripts

 

Island Health Inc.

CHC

A3

interface to the Mass HIway and implementing an opt in consent process. recent implementation of Allscripts electronic health record.

This is a natural extension of Island Health Care’s

$ 64,000

Island Health Inc. Total

     

$ 143,798

     

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

 

Island Health Inc.

CHC

D

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 re- occurrences.

$ 48,202

Island Health Inc. Total

     

$ 48,202

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

Lahey Hospital & Medical Center

CHC

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

Lahey Hospital & Medical Center Total

     

$ 908,882

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.

Lowell Community Health Center

CHC

C6

Strengthening the health center’s 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

Lowell Community Health Center Total

     

$ 419,999

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.

$ 345,499

Lowell General Hospital Total

     

$ 345,499

Lowell General Hospital

Hospital

C1

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

Lowell General Hospital Total

     

$ 203,040

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.

$ 1,137,800

Lynn Community Health Center

CHC

A2

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

$ 185,247

     

Delivering and enhancing the comprehensive continuum of enrollment services already developed, which includes outreach,

 

Lynn Community Health Center

CHC

D

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

Lynn Community Health Center Total

     

$ 1,608,416

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.

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 Manet’s EHR, AthenaHealth, and other data systems to improve Manet’s ability to manage care, and monitor outcomes and costs.

$ 116,904

Manet Community Health Center Total

     

$ 116,904

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

$ 39,356

Marlborough Hospital Total

     

$ 39,356

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.

$ 154,002

Milford Regional Medical Center Total

     

$ 154,002

Morton Hospital

Hospital

C2

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

Morton Hospital Total

     

$ 309,706

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.

$ 96,327

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.

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

 

North End Community Health Committee, Inc.

CHC

D

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

North End Community Health Committee, Inc. Total

   

$ 559,519

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.

$ 96,319

     

Expanding on last year's funding to focus on post-enrollment support, educating applicants about how to use the enrollee’s

 

North Shore Community Health

CHC

D

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.

$ 99,049

North Shore Community Health Total

     

$ 195,368

South Cove Community Health Center

CHC

C6

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

South Cove Community Health Center Total

     

$ 119,359

     

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.

 

South End Community Health Center

CHC

D

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.

$ 128,989

South End Community Health Center Total

     

$ 128,989

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

C2

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 hospital’s ED. The goal is to improve quality of care and generate cost savings.

$ 320,548

South Shore Hospital Total

     

$ 320,548

     

Enhancing organizational integration and collaboration among partner entities in preparation to implement a Medicaid accountable

 

St. Elizabeth's Medical Center

Hospital

B

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.

$ 1,668,229

St. Elizabeth's Medical Center Total

     

$ 1,668,229

     

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

 

Stanley Street Treatment and Resources, Inc.

CHC

D

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.

$ 35,545

Stanley Street Treatment and Resources, Inc. Total

   

$ 35,545

Tufts Medical Center

Hospital

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

Tufts Medical Center

Hospital

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

Tufts Medical Center Total

     

$ 641,501

UMass Memorial Medical Center, Inc.

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.

$ 512,923

UMass Memorial Medical Center, Inc. Total

     

$ 512,923

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UMass Memorial Medical Center, Inc.

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

UMass Memorial Medical Center, Inc.

Hospital

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

UMass Memorial Medical Center, Inc.

Hospital

C2

Identifying patient population that utilizes ED for non-emergency conditions and designing an intervention to reduce non- emergent 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

UMass Memorial Medical Center, Inc.

Hospital

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

UMass Memorial Medical Center, Inc. Total

     

$

885,229

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.

$

53,484

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.

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

Upham's Corner Health Committee, Inc. Total

     

$

59,174

Whittier Street Health Center

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

Whittier Street Health Center

CHC

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 Whittier’s Primary Care-based Care Management of opioid dependent patients.

$

348,944

Whittier Street Health Center

CHC

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 re- defining 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

 

Whittier Street Health Center

CHC

D

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

Whittier Street Health Center Total

     

$

817,794

 

$

20,000,000

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.