The following people make up The Kraft Center for Community Health's second class of Practitioners.
Project Topic: Bridging The Gap: Evaluation of a PCP-delivered brief CBT intervention to treat anxiety in primary care
Project Overview: There is a heavy burden of psychiatric illness, anxiety disorders and substance abuse on Cape Cod, with limited treatment resources, particularly counseling. This project will evaluate the efficacy and feasibility of primary care provider-delivered brief cognitive behavioral therapy to treat mild to moderate anxiety in primary care. Outcome measures will include the clinical effectiveness of the intervention for patients and its acceptability by providers.
Project Topic: Implementing a diabetes care plan for Latino patients at North Shore Community Health
Project Overview: The project seeks to implement a comprehensive diabetes management care plan for Latino patients that will include group visits and tools for diabetes self-management. Anticipated outcomes include improved patient knowledge of self-care, increased patient satisfaction, improved clinical outcomes and process measures, and the development of connections with local organizations that provide psychosocial supports.
Project Topic: Improving the rates of STD prevention, screening and treatment, targeting our 11 to 18 year old population at the pediatric clinic at Dimock Center
Project Overview: Sexual risk behaviors place adolescents at risk of contracting STDs, and a significant number of cases go undiagnosed because patients may be asymptomatic. This project will identify and implement interventions to increase STD prevention, screening and treatment, specifically HPV vaccination compliance, in the adolescent population at The Dimock Center.
Project Topic: Screening for schistosomiasis and strongyloides among Brazilian immigrants in the United States
Project Overview: This project will focus on screening for neglected tropical diseases (NTDs) such as strongyloides and schistosomiasis in a population of Brazilian immigrant patients. Specifically, thisproject will aim to determine the prevalence of positive serologies among patients at our health center. Collecting these data will further define current screening recommendations, develop the team model of care, and disseminate our findings through patient education with community health outreach.
Project Topic: Introducing psychiatry residents from VA sponsored resident program to women’s mental health in a community health center setting
Project Overview: This project will facilitate collaboration between Brockton Neighborhood Health Center leadership and the Psychiatry Residency Training Director at the Brockton VA in order to create a rotation for Brockton Psychiatry Residents at Brockton Neighborhood Health Center. Anticipated outcomes include improving the health center’s ability to recruit and retain psychiatrists and improving the availability of psychiatric services for the greater Brockton community.
Project Topic: CHAMPS: Becoming a behavioral health home
Project Overview: This project will transition Freedom Trail Clinic from a community mental health center to a behavioral health home through CHAMPS, coordinated health and medical prevention service. Anticipated outcomes include improved prevention and management of metabolic syndrome, higher rates of contact with a PCP and reductions in smoking.
Project Topic: Integrated treatment of people with severe mental illness and co-occurring substance use disorders
Project Overview: This project will develop an integrated treatment program for patients with both serious mental illness and a substance use disorder at Massachusetts Mental Health Center (MMHC). Anticipated outcomes include decreased psychiatric morbidity related to substance use, decreased utilization of inpatient psychiatric hospitalization for decompensation of psychotic illness, and increased patient-reported quality of life.
Project Topic: Establishing and evaluating shared medical visits
Project Overview: The Codman Square community, in its 2013 community health assessment, has identified diabetes as the community’s most important health problem. This project will plan, implement and evaluate a shared visit model for diabetic patients consistent with the health center’s patient-centered medical home goals. Anticipated outcomes include improved patient knowledge, increased patient and physician satisfaction, adherence to ADA recommendations, evaluation of barriers to healthy lifestyle choices, and improved values of patients’ metabolic parameters.
Project Topic: Transitions of care for hospitalized homeless persons
Project Overview: This project seeks to understand and subsequently improve the transition of care for homeless persons, many of whom are Boston Health Care for the Homeless Program’s patients, hospitalized at Massachusetts General Hospital. Anticipated outcomes include a better understanding of the inpatient and outpatient utilization patterns of homeless persons and the development of a transitional care model that focuses on discharge planning issues specific to homeless persons.
Project Topic: Developing the nursing workforce at North Shore Community Health to improve care in patients and increase staff satisfaction
Project Overview: This project will build on progress underway to develop and implement an organization-wide RN-led care management program at North Shore Community Health Center for managing complex patients. Anticipated outcomes include development of the RN Care Manager role, definition of “complex” or “high-risk” patients, improved coordination of care and outcomes for complex patients, and increased satisfaction of providers caring for complex patients.
Project Topic: Improving addictions care within the Lynn Health Center and establishing easily accessed continuum of care
Project Overview: The Lynn Community Health Center serves an underserved community with high rates of opioid related overdoses and significant polysubstance use and dependence. This project will evaluate the current addiction/buprenorphine program design and work on ways to increase access to addiction services at the health center.
Project Topic: Improving care for the diabetic population at the Family Health Center of Worcester
Project Overview: This project will implement a coordinated, systematic and patient-centered approach to diabetic care at the Family Health Center of Worcester, and will improve care by utilizing a team-based approach. Anticipated outcomes include increased patient participation in self-care, increased satisfaction of providers involved in the care of diabetic patients, creation of a clinically useful diabetic registry, and improved diabetic outcomes.
Project Topic: Identifying and implementing interventions to manage pediatric obesity in an urban community health center
Project Overview: This project will identify barriers preventing medical providers from effectively managing the care of their overweight or obese children and design relevant interventions. Anticipated outcomes include increased awareness of the pediatric obesity problem among multidisciplinary staff, better use of EMR to record and report data related to the problem, and the development and incorporation of self-management plans into the EMR.
Project Topic: Reducing “Churning” in a safety net health care system
Project Overview: High rates of insurance ‘churning’ - or cycling on and off insurance- disrupt care for many low-income patients at Cambridge Health Alliance (CHA) and East Cambridge Health Center. This project will undertake a pilot study to determine the feasibility, acceptability and efficacy of a text message intervention to help reduce churning. Anticipated outcomes include: improved understanding of patient preferences for text message communication at CHA; adapted and tested text message reminder intervention; and assessment of rate of churning among those exposed to a text message reminder intervention.