SAMHSA grant: “Enhancing Systems of Care”

CHA’s Children’s Health Initiative (CHI), under the direction of PI, Dr. Katherine E. Grimes, has been awarded a 4-year system-of-care grant from the federal Substance Abuse and Mental Health Services Agency.

  • Start date: Funding runs 9/30/16 – 9/30/20, and wil be managed within Sponsored Research
  • Pilot Experience: E-SOC builds on 12 years of success with the Massachusetts MHSPY model for community-based, interagency strategies related to improving child outcomes, leveraging social determinants of health; as well as recent Windsor St. Collaborative Practice Model, CHA’s pilot for motivations in integrated care delivery within Pediatrics.
  • Population: Children, 3 – 18 years old, with PCP’s in CHA, who are referred from primary care having either screened positive for ‘serious emotional disturbance’ or where the PCP notes specific predisposing risk factors.
  • Sites: Primary Care clinic ‘hub’ sites include Windsor, Broadway, Everett and Malden (hub sites must be located within Middlesex Co.)
  • Scale: While screening will be done on all (approx. 25,000) children in CHA, E-SOC anticipates primary care child psychiatry outpatient consultation rates of approximately 150 children/year.

Specific Goals of CHA’s E-SOC Project:

  • To improve access to child mental health and substance abuse (MH/SA) care – expand primary care screening and increase availability of timely evaluation and treatment, with a special focus on recognition and response to childhood trauma.
  • To improve youth and family engagement in MH/SA care – including greater communication between parents/caregivers and clinicians, and processes for outreach and tracking of referrals, as well as reduction of barriers such as language, culture, affordability and distance.
  • To improve clinical functioning – as reported by mental health providers, families, as well as self-report by youth with mental health needs.
  • To enhance integrated care delivery – including more real-time opportunities for collaboration; direct and indirect ways to “share care” between Primary Care Pediatrics, Family Medicine and Child Mental Health, with resulting increases in individualized treatment plans and adherence.
  • To improve community-linkages; with parent advocacy groups (PPAL, NAMI), school systems, and child-serving agencies, such as child welfare (DCF), and mental health (DMH), as well as with Cambridge and Somerville Police, and specialty substance abuse (IHR)


  • Registry: Create a Child Mental Health/Substance Use Risk Registry: using population-wide screening, with age-appropriate instruments, to identify and manage mental health needs.
  • Intervention: Identified youth and families will receive a multi-faceted integrated care consultation, which combines diagnostic evaluation, family assessment, and multi-disciplinary, team-based treatment recommendations, and follow-up community linkages and support.
  • Roll-out: We intend to expand and transport our “Collaborative Practice” (Windsor St.) model to the four ‘hub’ locations; we will have onsite Family Support Specialists, child psychiatry resources and a (new role) Clinical Care Manager, at each hub.

The E-SOC child integrated care teams will continue to rely on the three defining activities of the Collaborative Practice Model: co-location, coordination and collaboration. However, recognizing that each hub will have its own culture, we will work closely with clinic leadership and provider teams to identify which characteristics of our Windsor St. pilot approach are readily transportable, what may need adapting, and any new elements that would be likely to increase effectiveness and further improve outcomes.

Throughout the E-SOC implementation process and evaluation, we will maintain our focus on the overarching hypothesis, which is that earlier, and more comprehensive, integration of care for children will improve health care quality and expense outcomes throughout the lifespan.