Teaming Up to Address Mentally Ill Patients In Lynn

Thanks to a competitive grant from the Massachusetts Health Policy Commission, a new program is taking shape at the Lynn Community Health Center (LCHC) that could have a profound impact on one of our community’s most underserved populations: patients suffering from debilitating mental health and substance abuse issues.

The program, led by Lynn Community Health Center CEO Lori Abrams Berry and Chief of Behavioral Health Mark Alexakos, MD, will test an innovative, patient-centered care delivery model to better meet the needs of the seriously mentally ill. At the core of this program are two key components: remote monitoring technology to dispense medication and improve adherence in the home; and specialized community health workers to help coordinate care inside and outside of the LCHC.     

“These are patients with serious mental illnesses and substance abuse disorders: schizophrenia, major depression, repeat visits to the ER, and they typically live alone or on the street,” Alexakos said. “This is not a patient population that has a lot of support—they’re the most challenging population in the Medicaid program.” 

The challenges come from many angles. These patients often disproportionately experience unmet needs including stable housing, reliable transportation, food security, social and familial supports. Uncontrolled medical conditions like hypertension, asthma, diabetes, obesity, and tobacco use occur at higher rates, and patients are often disengaged from primary care and/or behavioral health care. These challenges, combined with complex behavioral and medical needs, contribute to difficulty adhering to care plans, managing medications, and making scheduled appointments. Understandably, caring for this population can be costly.