Community Health Worker Initiatives

Hospital to Housing tenant, Darrin, sharing his experience with the program. 


Meeting Health Care Needs, Ending Homelessness

Chronically homeless people often struggle with complex physical and behavioral disabilities that are made worse by years without stable housing. They frequently visit emergency rooms and other expensive acute care options in order to address their medical concerns, but the care they do receive is short-term and costly to taxpayers. The medical field has come to realize that housing is one of the main social determinants of health that needs to be addressed in order to improve healthcare access. By providing people with stable housing, they are able to work on – and improve – their medical needs.

MHSA’s newest initiatives, Hospital to Housing (H2H) and Health Care for Housing (HCH) are testing ways to correct these systems issues with innovative and less costly approaches. These programs connect chronically homeless individuals with less expensive, more appropriate health care and with stable housing.


Hospital to Housing (H2H)

Funded through a major three-year United Health Foundation (UHF) grant, H2H is a unique partnership between MHSA and one the of the Commonwealth’s Managed Care Organizations, Beacon Health Options/Massachusetts Behavioral Health Partnership (Beacon/MBHP). Five Community Health Workers (CHWs), hired by MBHP and stationed in Boston, Lowell and Pittsfield, provide personalized care to a targeted group of chronically homeless people with complex health needs and high emergency medical costs. The CHWs help these individuals navigate the medical system, and more importantly, secure stable, permanent housing with ongoing supportive services. 

Providing Personalized Support

From doctor appointments to housing applications, the CHWs provide customized support to each participant. According to Kara Bray, Senior CHW, "community health workers lead our [participants] to better health outcomes and a better quality of life. We advocate for what the individual needs to achieve their personal goals."

As of June 2019, 75 H2H participants have been housed. Furthermore, the CHWs work with participants to help them access primary care, behavioral health, community-based supports, work opportunities and job training programs.  

Measuring Success

Medicaid claims data is obtained and analyzed by MBHP before and after the H2H intervention, including the cost and type of utilization, such as ambulance rides or emergency room visits.

Early medical data indicate this approach is reducing costs; once homeless individuals connect with a CHW, they use emergency services less and outpatient and primary health care more. But the claims data tell only part of the story. Not only have costs dropped, BUT complicated health care challenges are finally being appropriately treated and participants are finally in stable permanent housing. Their homelessness has ended, their health care needs are better addressed, and their quality of life is improved thanks to this innovative MHSA partnership.


Health Care for Housing (HCH)


Heidi Nelson, CEO, Duffy Health Center, and Joe Finn, President & Executive Director, Massachusetts Housing & Shelter Alliance, with Massachusetts Attorney General Maura Healey at the press conference announcing the Attorney General’s Office Social Determinant Partnership Grant.

In January 2019, MHSA was selected as a recipient of the Massachusetts Attorney General’s Office Social Determinant Partnership grant program. Thanks to this generous support from the Commonwealth, MHSA is partnering with Community Healthlink in Worcester, Duffy Health Center in Hyannis and Mercy Medical Center – Health Care for the Homeless Program in Springfield as part of a new initiative called Health Care for Housing (HCH).

For the HCH initiative, one community health worker (CHW) is stationed at each of the three community health centers to provide personalized care to a targeted group of chronically homeless individuals with complex health needs. The CHWs help these individuals navigate the medical system, and more importantly, help them secure stable, permanent housing coupled with ongoing support services.

HCH is a continuation of MHSA’s work to develop innovative, systemic solutions to end chronic homelessness. Similar to other collaborative, community-based MHSA programs, such as its successful Hospital to Housing program, this new initiative will further demonstrate the value added by CHWs working with the chronically homeless population and the role housing plays in reducing emergency healthcare utilization.



Massachusetts AG Maura Healy Gives $ million to Address Social Factors that Affect Health – Masslive

New Counseling Model Helps Homeless Find Stability – WGBH: Boston’s Local NPR Affiliate

Beacon Partners in Hospital to Housing Initiative – Beacon Health Options