Mr. Tucker 73, lives alone in the Blackstone Senior Housing, just across Blossom Street from MGH. During his annual meeting with his building manager to discuss rent and finances, he acknowledged that he had not seen a doctor in two years. His doctor was located in the suburbs and travel there by subway had become too difficult. The building manager suggested that Mr. Tucker meet with MGH Senior HealthWISE nurse Cheryl Wall, RN, during her weekly session in the building. During the initial visit with him, Cheryl discovered that he had a number of serious health problems that had gone unmanaged. Mr. Tucker’s health was seriously threatened, but then Cheryl swung into action. Her next visit with Mr. Tucker was in his home, where she sorted through medications with him, connected him to primary care at the MGH Senior Health practice, and scheduled appointments for him at MGH podiatry and nutrition, and at Mass. Eye and Ear Infirmary. Cheryl continues to meet with Mr. Tucker at the wellness clinic in his housing complex. His diabetes now is under control and he is doing much better.

MGH Senior HealthWISE is one of many MGH Center for Community Health Improvement programs created to improve access to care for vulnerable populations. Senior HealthWISE recognizes that the presence of medical services in the neighborhood where seniors live does not necessarily assure access to care. Financial, cultural, linguistic and other barriers often exist. Programs like Senior HealthWISE and those listed below seek to reduce those barriers and improve access.

Boston Health Care for the Homeless Program at MGH
James J. O’Connell, MD

The Boston Health Care for the Homeless Program (BHCHP), founded in 1985 with a Robert Wood Johnson Foundation grant to the City of Boston, delivered health care to more than 9,500 individuals in 2007.  The BHCHP service delivery model integrates care at three hospital clinics with care at clinics in over 70 shelters and soup kitchens and other sites familiar to homeless individuals and families. The BHCHP mission is to assure the highest quality health care to all homeless individuals and families in the greater Boston area, and to decrease disparities in morbidity and mortality suffered by the homeless poor. 

The cornerstone of the BHCHP model of care is a trusting relationship between patients and clinicians that assures continuity, consistency, and coordination of care.  BHCHP teams of doctors, nurse practitioners, physician assistants, social workers, and nurses offer direct care in shelters, soup kitchens, transitional programs, and directly on the streets. These same clinicians follow their patients in primary care and specialty clinics, in the Emergency Department (ED), during inpatient hospitalizations, through medical respite care at the Barbara McInnis House, and with home visits whenever chronically homeless persons find housing.

MGH was one of the original three Boston based hospital sites for BHCHP, and was the first private academic medical center in the nation to create and support an on-site health care for the homeless clinic. This relationship has flourished for more than two decades. BHCHP at MGH offers primary care in the Medical Walk In Unit (MWIU) and strives to coordinate care delivered to homeless patients throughout MGH, especially in the specialty clinics, the ED, and inpatient medical and surgical services.

BHCHP provides care at numerous locations, including:

• BHCHP practitioners see homeless patients five days at week in the MWIU. With almost 2500 visits per year, BHCHP accounts for 10 percent of all care delivered at this easily accessible location. Two exam rooms have proven insufficient to meet the growing need for primary care for homeless persons seen in the ED, and additional space is being sought which will allow for more patient visits.
• BHCHP at MGH clinicians also deliver care at community-based locations, including the Pine Street Inn and Overnight Van, St. Francis House, Pilgrim Shelter, New England Shelter for Homeless Veterans, and St. John of God Church and the Church of the Advent, both on Beacon Hill.
• BHCHP operates the Barbara McInnis House (BMH), a 90-bed respite care program in Jamaica Plain that offers a cost-effective alternative to prolonged acute care hospitalization. BMH provides acute and sub-acute, pre- and post-operative, recuperative and rehabilitative, palliative and end-of-life care to homeless persons who are too ill or injured to withstand the rigors of life on the streets and in the shelters. This innovative model fills a widening gap in the health care system for those without the safety and support of a home and family, and has demonstrated dramatic reductions in lengths of stay for homeless persons admitted to MGH.
• BHCHP’s Street Team provides care to Boston’s “rough sleepers”, including a high-risk cohort of people with acute and chronic medical problems who have been sleeping regularly on the streets for six months or more. A special “Thursday Clinic” in the MWIU is the only hospital clinic in the country dedicated to those who live on the streets. The Street Team provides care in a variety of unconventional settings: under bridges, down back alleys, in abandoned cars, on park benches and street corners, in soup kitchens, overnight drop-in centers, EDs, detox units, and nursing homes. These itinerant homeless persons face overwhelming obstacles to health and health care, including exposure to the extremes of heat and cold, trauma, violence, complex and chronic medical illnesses, persistent mental illness, and substance abuse. The Street Team has an innovative approach to the integration of medical and mental health care through a multidisciplinary team of three internists, a psychiatrist, a physician assistant, a nurse practitioner, a social worker. These dedicated professionals combine a consistent and trusting presence on the streets with aggressive follow up, allowing a continuum of care from street corner to ICU to respite care, while fully integrating care into Boston’s mainstream health care system. Through this approach, which respects the vicissitudes of life on the streets, especially hard to reach homeless persons receive care for the most serious and often co-existing conditions, as well as flu vaccines, cholesterol screening, Pap tests, mammograms, and prenatal care.

Boston’s ability to follow such an unusually peripatetic urban cohort over time has not been duplicated in any other large urban city. This is an extraordinary testament to the collaborative network of community partners who share in the care of this disenfranchised population, including: the outreach teams from Pine Street Inn, HopeFound (formerly known as Friends of the Shattuck Shelter), and Tri-City Mental Health Center; the academic teaching hospitals (especially the EDs of Boston Medical Center and MGH); the Area A Police Department; the Emergency Shelter Commission and the Emergency Medical Services of the City of Boston; and the Massachusetts Departments of Public Health, Mental Health, and Transitional Assistance. 

BHCHP participates in a MGH ED Task Force with a goal of improving the care of homeless individuals with high utilization rates. This multidisciplinary team of health care providers, case managers, social workers, and staff develops and implements practical treatment plans which are kept updated in the ED for reference whenever homeless patients present for care.

BHCHP is actively preparing future physicians in the art and skill of caring for homeless persons. The program developed and implemented a lecture series on health care and homelessness that is a required component of the MGH medical residency curriculum. During the ambulatory block, MGH residents learn about the history, epidemiology, and clinical issues of homelessness as well as the obstacles to access and continuity of care. Primary care residents join BHCHP staff for community and street clinics during their ambulatory rotations.  Four of the team’s physicians serve as faculty members in Harvard Medical School’s Primary Care Clerkship, while five of BHCHP’s 16 active physicians are graduates of the MGH Internal Medicine Residency Program.

2007 Program Accomplishments

• In recognition of MGH’s 22-year relationship with BHCHP, Partners gave a gift of $2.5 million, their largest gift yet given, to support the renovation of the former Mallory Institute of Pathology on the corner of Massachusetts Avenue and Albany Street. This site of the former city morgue will be renovated and house a 104-bed medical respite care unit as well as an integrated medical, mental health and oral health clinic.  This building will open in summer 2008.
• BHCHP at MGH physicians Patrick Perri, Elizabeth Cuevas, Monica Bharel, Allyson Bloom and James O’Connell spent a total of three months attending on the inpatient medical service at MGH.
• BHCHP clinicians and MGH emergency department staff meet quarterly to improve treatment plans and options for homeless people who are frequent users of the MGH ED and other services.
• To better understand the utilization patterns and numbers of homeless individuals served by Partners, the Center for Community Health Improvement compared the BHCHP patient database with the Partners database and found over 3,000 homeless individuals were served each year by MGH and Brigham and Women’s Hospital. Utilization rates of ED, laboratory, and specialty services were high, as were lengths of stay compared to other patients. This preliminary data is now being analyzed in greater depth and the results are pending
• BHCHP and HomeStart have collaborated for the past two years in an innovative “housing first” pilot program to house medically frail homeless persons who have been living on the streets of Boston for over five years.  Of the 28 individuals housed through this program, 22 (79 percent) remain in their apartments while one has been evicted, one is now disabled and permanently in a nursing home, and four are deceased.  BHCHP’s Street Team follows each of these individuals closely, providing 24 hour medical and supportive care seven days a week.
• BHCHP has continued a robust involvement with inpatient care in collaboration with the MGH nurse case managers.  The goals have been to identify all homeless inpatients, assure each patient has a PCP, work together on practical treatment plans, and minimize LOS by fostering safe discharge dispositions and timely access to BHCHP’s Barbara McInnis House.
• Of the 350 homeless inpatients seen by BHCHP at MGH, the most frequent discharge disposition was McInnis House (102 individuals, or 29 percent). 
• First-year residents from the Department of Psychiatry now participate for several sessions in the waiting room of the busy Thursday Street Clinic, interacting with homeless persons who live chronically on the streets and have limited access to mental health care.
• With funds from MGH, BHCHP has collaborated with DMH and Massachusetts Mental Health Center to begin two pilot multidisciplinary teams that will offer homeless persons a “medical home” that fully integrates medical and psychiatric care.  Psychiatrists who are fully credentialed within DMH and have full access to all of DMH’s mainstream services will join the BHCHP teams.  These clinicians will work side-by-side the medical and nursing staff in the BHCHP clinics and outreach sites as well as at the Barbara McInnis House.  This innovative pilot program will enhance continuity and coordination of care, and hopefully be the catalyst to systemic changes at both BHCHP and DMH. 

2007 Program Data

• BHCHP at MGH had 2489 primary care visits in the MWIC during calendar year 2007.
• MGH Thursday Street Clinic has burgeoned: 1946 individuals received services – for medical and mental health care, social services, meals, clothing, and assistance with benefits and housing - in 2007, an increase of 38 percent from 1407 persons served in 2006.
• Of a total of 1574 admissions to BMH during 2007, 261 (17 percent) came directly from MGH, including 34 from the ED, 88 from inpatient services, and 139 from outpatient clinics and day surgery.
• BHCHP physicians at MGH provided 350 consults on patients, an increase of five percent from 2006.  Consults were spread among the following services: medicine (79 percent);   surgery (11 percent)); ED (five percent); neurology/neurosurgery, (three percent); psychiatry (three percent); and OB/GYN (0.3 percent).
• A BHCHP nurse spends two afternoons a week with MGH nurse case managers in an effort to reduce hospital lengths of stay through timely and efficient admissions to BMH.   During 2007, 306 people were screened in 686 consults.
• The BHCHP Street Team has prospectively followed a cohort of 119 individuals identified in 2000 as high risk for adverse health outcomes and mortality. This cohort has now been followed for eight years, and the dispositions at the end of 2007 are as follows:
• Deceased                     46 (39 percent)
• Housed                        48 (40  percent) 
• Streets                            7 (6 percent)  
• Nursing Home                9 (8  percent) 
• Shelter                            4 (3 percent)
• Lost to Follow-up           3 (3  percent)
• Incarcerated                   2 (2 percent) 
• The BHCHP Street team saw 1,385 patients in 5239 encounters during calendar year 2007 (compared to 1140 patients in 5849 encounters in 2006).  The number of unique individuals increased by 21 percent, while the number of encounters decreased by ten percent.   
• An active “High Risk” cohort of 145 individuals was followed more intensely during the year because the severity and complexity of their medical, mental health, and substance abuse problems place them at risk for poor health outcomes and high mortality rates.  Of these, 79 percent received flu vaccination (or were offered and refused). Among female patients, 45 percent had Pap smears, and 56 percent had mammograms.

The demographics for this group included:

• Male                            116  (80 percent)
• Female                          29   (20 percent)
• White                           110  (76 percent)
• Black                           15    (10 percent)
• Native American           10    (7 per cent)
• Hispanic                         5    (3 percent)
• Undetermined                 5    (3 percent)
• Average Age                53 years old
  
  Among this “High Risk” cohort, 66 individuals accounted for 208 admissions to the Barbara McInnis House (BMH). The number of admissions per patient ranged from one to 11, while the length of stay (LOS) ranged from one day to 194 days, with a mean of 20 days.  This high risk cohort accounted for a total of 3019 inpatient days at BMH.

MGH Residency Community Medicine Experience
Valerie Stone, MD, Associate Chief, General Internal Medicine Unit, Director, Primary Care Program
Celina Garza Mankey, MD, Assistant Director, Primary Care Program

The community medicine experience was implemented in July 2002 with support from the Department of Medicine and MGH Center for Community Health Improvement. The goals of the program are to increase medical residents’ (doctors in training) awareness of and familiarity with community health programs and resources, and to provide residents with experiences in community settings, which will improve their comfort with and knowledge of diverse patients and communities. Through the experience, residents are exposed to programs serving underserved communities and have the opportunity to design and implement a community health project to meet needs of a special population being served by a community program.

The experience takes place during Ambulatory Care Rotation (ACR). Primary care residents and categorical residents stating an interest spend time at community sites once or twice a week. So far, 130 primary care and categorical residents have rotated through the experience during their ACR block. Many have been to different community sites as they have rotated through ACR more than once. Five to eight residents are involved in a community medicine rotation every month.

This year, the focus of the primary care research curriculum was on teaching residents about community based participatory research, and on how to start thinking about developing a community project. Several lectures on community health assessment were also held.

In addition, several residents have been involved in community health projects that they have designed and implemented. Community sites and projects have included:

* Boston Health Care for the Homeless, including the Barbara McInnis, St. Francis House and Methadone clinic
* Rosie’s Place
* Shattuck Hospital HIV/Hepatitis C clinic and HIV/TB clinic
* MGH Chelsea Health Center ROCA clinic (Reaching out to Chelsea Adolescents)
* MGH Charlestown Health Center including Encuentro Latino, McLaughlin and House Kennedy Center
* MGH Revere Health Center Hepatitis B project
* Codman Square Health Center Urgent Care Clinic
* South Cove Health Center
* Family Van (various sites across the city)
* Geiger-Gibson Health Center
* Boston Living Center
* BMC Refugee Clinic

MGH Senior HealthWISE
Barbara E. Moscowitz, MSW, LICSW, Program Director
Frank D. Bellistri, MS, RN-CS, GNP, Nurse Practitioner
Lindy A. Wilks, BA Health Educator
Shelley H. Amira, MPH, Administrator

The mission of MGH Senior HealthWISE (Wellness, Involvement, Support, Education) is to enhance the health and well being of older adults in Boston's West End and Beacon Hill neighborhoods. The program’s design and operation reflects collaboration with the Massachusetts General Hospital’s Geriatric Medicine Unit and the Departments of Social Services, Patient Care Services, Nutrition and Food Services, Volunteer Department, and the Institute of Health Professions, as well as many community agencies. The chief components of HealthWISE are weekly health and wellness clinics for residents of three neighborhood housing developments, and educational and wellness programs for all older adults in the community, held at the hospital campus. All programs in the buildings and MGH are available at no cost.

Wellness Clinics
Many older, frail adults become disconnected from available healthcare services because they are overwhelmed, confused or intimidated by complicated systems. The goal of the Wellness Clinics is to improve an individual’s self-care and health management. This is done through education and support, and by strengthening the connection between the resident and their available resources including their physician, social worker, mental health worker, and other community service providers. In addition, social connections and community-based activities are encouraged as necessary components of wellness. Successful interventions might include the clarification of an individual’s medication regimen, treatment recommendations prescribed by the primary care provider, or referral to social or support group.

The Wellness Clinics have been open for two and a half years, and meet weekly for three-hour sessions at each of the three local buildings; The Amy Lowell, Blackstone, and Beacon House. HealthWISE provides each building with appropriate medical equipment and supplies, and the service is free of charge to residents and building staff. Individuals are registered and are required to provide consent for communication between Senior HealthWISE staff and other designated healthcare providers. A number of residents are followed at the Veterans Hospital, New England Medical Center, and Boston Medical Center, in addition to MGH.

An MGH registered nurse and health educator staff the clinics. To date, the program has enrolled 202 residents and this year conducted 475 nursing and health educator visits in 2004. The reduction in visits from the previous year reflects the success of the team in connecting individuals to health care providers, stabilizing health and social crises, and supporting independent functioning by reducing weekly appointments to monthly, or as needed. Upon the request of building managers, the team conducts home visits to frail residents unable to attend the Wellness Center. Some of these visits have resulted in hospitalizations of individuals in crisis. Others have averted unnecessary visits to the emergency department (ED), instead triaging people appropriately to their primary care providers.

The types of nursing visits and support include, but are not limited to:

* Screenings: Memory loss, hypertension, cholesterol,
* Routine: Blood pressure check, glucose checks (diabetes)
* Follow-Up: Hypertension, diabetes, caregiver stress, congestive heart failure, depression, explanation of lab results, medication issues, sleep disorders, and supportive education for chronic illness management.
* Episodic: Anxiety, stroke, cellulitis, gait instability, leg edema, memory deficits, dysphasia, hearing loss, medication issues, chest pressure, pain, dental issues, and urinary incontinence.
* Home Visits: Recent hospital discharge, medication checks, dehydration screens, home bound resident “check-in”, confusion, disabling depression.
* The Wellness staff also provide support and education to the building management and other agencies that work with the residents in the buildings (i.e. Boston Senior Home Care).

The goal of the Health Educator is to identify individuals who are eligible for community services, and guide them through the referral process. HealthWISE has worked closely with Little Brothers- Friends of the Elderly, Match-UP Interfaith Volunteers, and Boston Senior Homecare to facilitate referrals for medical escort and homecare services. Additionally, assistance is provided to residents with concerns about cost of medications, obtaining adaptive equipment, and in accessing health care insurance.
The team, including the Program Director, a clinical social worker, has responded to crises in the buildings, which have included staff and resident deaths. They conduct bereavement sessions for residents as necessary, and remain available to assist with assessment, referral, and consultation to management.

In addition to individualized attention, HealthWISE has provided health promotion programs and screenings for all residents in each of the buildings. Increasingly, the goal of HealthWISE is to encourage individuals to attend health promotion programs that are sponsored in the hospital. For those who are capable, journeys outside of their apartment are critical for exercise and socialization. Topics to date have included:

* Meditation workshop
* Fall Prevention and Screenings provided by IHP Physical Therapy Students
* Cholesterol Screenings
* Flu clinics
* Nutrition workshops

HealthWISE Lecture Series
The program sponsors a community lecture series for all older adults in the community. For the first lecture series in 2002, attendance ranged from 6 to 25. This year attendance has increased, and ranges from 25 to 50, with new attendees from the West End and Beacon Hill neighborhoods. Past program topics have included: Healthy Cooking for One, Age Appropriate Exercise, Vitamins & Supplements, Arthritis, Advanced Directives, and Grief and Loss and many others. The lectures continue to be free of charge and open to all seniors. Programs are advertised throughout the community in the Beacon Hill Times, The Regional Review and the MGH Hotline.

Senior Supper Club
The Senior Supper Club is a community program for individuals aged sixty and older. This program offers a 10 percent discount on food at MGH cafeterias and products from the MGH Retail Shops, which include Images Hair Salon, Flower Shop and General Store. The Supper Club hours have been extended and now include breakfast.

Flu Clinics
Flu clinics were offered in each of the three buildings this year for residents who were 75 and older, in accordance with the Department of Public Health regulations at that time. In addition, one free community flu clinic was held at the West End Public Library. To address the early concerns of a flu shot shortage, HealthWISE sponsored a seminar at MGH entitled, “Flu Season Without a Flu Shot: What Do I Need to Know?” The HealthWISE nurse, and a member of the MGH Infection Control Unit were the speakers.

HealthWISE and The Clubs at Charles River Park
HealthWISE has partnered with The Clubs at Charles River Park to provide special programming. The health club, in conjunction with HealthWISE, offers free exercise workshops for all community seniors. Programs to date include:

* “Sit to Be Fit”
* “Stretch and Relax”
* “Strengthen and Lengthen”

As part of a new initiative for community seniors, HealthWISE and The Clubs at Charles River Park will be offering an exercise program, which will meet 3 times per week. HealthWISE sponsored the training of the staff at the Clubs, and they are now certified fitness instructors of the Lifetime Fitness Program. The program is designed to be safe and effective for seniors with a wide range of physical abilities. It includes strength training with ankle and wrist weights, as well as aerobics, stretching and balancing exercises. Studies have shown a marked improvement in participants’ physical functioning, as well as a decline in areas such as pain, fatigue, and depression.

ACCENT
Action for Boston Community Development (ABCD) was awarded a grant to provide nutrition education to low income elders who are at risk for poor nutrition. HealthWISE is a collaborating partner in the grant along with The City of Boston and Boston Medical Center. HealthWISE staff assisted in developing the curriculum for the project, which has since been effectively implemented at two other community locations. The intensive twelve-session curriculum includes education on various nutrition topics such as:

* How to read food labels
* “Good fats vs. bad fats”
* Low Sodium Cooking
* Healthy Cooking Techniques
* Food Safety
* Barriers to Healthy Nutrition

The program ran during the winter and spring 2004, and provided inspiration for a new collaboration with the MGH Department of Food and Nutrition Services. They are working to develop a new course on nutrition, which is scheduled to begin in January 2005.

Health Enhancement Program: Research
HealthWISE has adopted a new research based wellness model called The Health Enhancement Program (HEP), which is a component of the Senior Wellness Project of Seattle King Senior Services. In collaboration with a National Institute of Aging funded researcher, HealthWISE is disseminating the program as a small pilot research study. HEP is now implemented in the Beacon House, and will be introduced to the Blackstone in six months. Guided by the outcome of the pilot, HealthWISE plans to integrate the model into all three Wellness Centers as regular programming.

Program participation includes an initial assessment, personal guidance, and support to the senior in making better choices about their own health. Individual goals typically address nutrition, exercise, depression, smoking cessation and socialization. The HealthWISE team is designing and will staff Support Groups and programs as part of the initiative.

Avon Breast Cancer Outreach Program
Atala Esquilin, Avon Breast Cancer Outreach Worker
Diana Maldonado, Cervical Cancer Outreach Worker
Sheila Jewett, MSW, MGH Chelsea
Denise Sidorowicz, ANP, MGH Chelsea

MGH Chelsea is one of three sites for an innovative program aimed at improving access to breast health services for underserved women. The program is funded by The Avon Foundation and is conducted in collaboration with the Avon Comprehensive Breast Evaluation Center at MGH and Partners Community Benefits. Other program sites include Mattapan Community Health Center and Geiger Gibson Community Health Center /Harbor Family Health Center. In Chelsea, the program conducts outreach to women at risk for breast cancer both within the health center and the greater community and helps women navigate the array of breast health services available at MGH Revere and MGH Boston.

Since its inception in May 2001, the program has served 332 patients including 42 patients with breast cancer (33 diagnosed while in the program and nine breast cancer survivors). Most patients are referred with an abnormal finding on a mammogram or clinical exam. Others are referred because they have repeatedly missed mammography appointments. All are helped to receive the screening, diagnostic, therapeutic or support services they need. Chelsea’s Avon Breast Cancer Outreach Program is open to all patients but targets Latin American women, whose breast cancer mortality increased 38 percent in Boston between 1991/94 and 1995/97. Since the program began, 62 percent of the patients served have been Latinas.

An important component of this program is the creation of a close clinical linkage to the Avon Comprehensive Breast Evaluation Center at MGH. Patients from Chelsea who have an abnormal finding and need further evaluation attend a designated clinic at the MGH Breast Center every Thursday morning. These specialized appointments are designed so that the patient can have ‘one stop shopping’ including ultrasound, mammography, as well as appointments with pathology, radiology, oncology and surgery, all accompanied by a Spanish interpreter. This system allows patients to schedule their specialty appointments within one week of an initial finding.

Another important component of this program has been the creation of two breast cancer support groups – one in English and one in Spanish – conducted by an MGH Chelsea social worker. These groups provide mutual support and the opportunity to share personal experiences with various treatments and issues arising from treatment. Issues include language and cultural barriers to care as well as assistance obtaining concrete needs, such as transportation, wigs or headscarves and food vouchers. Group members discuss how to ask questions of their caregivers and how to advocate for themselves. Participants also receive language appropriate educational material. The Spanish language support group is the only one of its kind for breast cancer survivors in the Boston area.

During the winter of 2005, the social worker plans to restructure the support groups using a model developed by Michael H. Antoni, Professor of Psychology at the University of Miami. The approach, called the Breast Cancer Stress Management and Relaxation Training or B-SMART, is a resiliency model that supports psychosocial adjustment, physiological functioning, and positive health outcomes for women with breast cancer.
The approach includes cognitive-behavioral interventions such as reframing and positive thinking (e.g., optimism about the outcome of their cancer diagnosis). The most important function of a support group is to unite the members to help foster a sense of cohesion and universality to help combat feelings of alienation that can come up in dealing with a cancer diagnosis. The social worker has found this to be especially true for Latin American women and believes that the B SMART group will be a more effective way to achieve this. Up to eight participants will meet weekly for two hours over ten weeks. Patients who complete the ten-week series will be offered a monthly drop-in group for continued support. The B SMART groups will be offered to women with breast cancer primarily, but will be open to women with other diagnosed forms of cancer, including cervical cancer.

In September of 2004, the Gillette Center for Cancer Care at MGH provided funding to expand services to women dealing with cervical cancer. The Cervical Cancer Outreach Worker works closely with the Colposcopy Clinic at MGH in Boston, ensuring that patients from Chelsea get to both their initial and follow up appointments and ensuring that communication flows easily between the providers at the two sites. The outreach worker often accompanies patients to their appointments to answer questions and provide support. The Cervical Cancer Outreach Worker is also one of the Spanish interpreters at MGH Chelsea part time, so she is very familiar to many adult Latina patients. Having the outreach worker linked directly with the Colposcopy Clinic, calling patients to remind them of appointments and working with patients to address their concrete barriers to care, has significantly decreased the no-show rate for colposcopy appointments for Chelsea patients.

Bridging the Gap - The Refugee Family Service Project
Adnan Zubcevic , Refugee Counselor
Tamara Leaf, PhD, MGH Chelsea
Elizabeth Miller, MD, Harvard Medical School and MGH Revere
Samar S. Hassouneh, Harvard Medical School
Lipika Goyal, Harvard Medical School

As an outgrowth of the Immigrant and Refugee Health Program, The Refugee Family Service Project was created in collaboration with volunteer students from Harvard Medical School. In this past year, which was the fourth year of this project, Bridging the Gap received a Pathways to Culturally Competent Health Care Grant from the Massachusetts Blue Cross and Blue Shield Foundation. This funding allowed the project to hire a part-time coordinator and a clinical advisor. The program also added more educational components for both Harvard Medical students and refugee families. In the 2003-2004 academic year, 25 students, with varying linguistic and cultural experiences, were paired with 25 newly arriving refugee and immigrant families from Afghanistan, Sudan, Morocco, Western Africa, Central Africa and Latin America who receive their primary care at MGH Chelsea.

The students supported the families in addressing simple health-related needs and acted as advocates, educators, mentors and friends as the families continued the process of adaptation to life in a new country. The project provided the students with the opportunity to support refugee families with concrete needs, while learning first hand the cultural issues that pose challenges to the provision of primary health care. The project gathered all of the families together several times in larger events as well, including field trips, dinners and cultural celebrations. The past year’s activities included four focus groups in five languages, two in-depth educational workshops for the families and one family and student celebration. Trainings were held for the students, including one led by staff from the International Rescue Committee focusing on issues faced by refugees. All these events were geared towards enhancing provider-patient interaction. In effect, the program is meant to “bridge the gap” between cultures, languages and experiences and to open communication channels between providers and the communities they serve.

Cervical Health Outreach Program
Diana Maldonado, Cervical Health Coordinator
Denise Sidorowicz, ANP, MGH Chelsea

The Cervical Health Outreach Program aims to increase rates of follow-up for women, including adolescents, who have had abnormal pap smears, with the goal of preventing cervical cancer. The program is delivered to patients of MGH Chelsea who are undergoing diagnostic follow-up and treatment for cervical cancer, with an emphasis on reaching Latina women.

The program’s Cervical Health Coordinator works closely with the Center for Colposcopy at MGH to ensure that patients from Chelsea attend initial and follow-up appointments, and to facilitate communication between MGH specialty and MGH Chelsea primary care providers. The coordinator provides emotional support, assistance with reminding and scheduling appointments, helps accessing insurance, and accompanies patients to appointments and/or conducts home visits as needed. The coordinator ensures that patients follow through in getting their second and third HPV vaccines once they have begun their vaccination schedule at the Center for Colposcopy. The coordinator also conducts outreach to inform the community about the program. The program’s expansion to include adolescents presents unique challenges, since teens often require more time for education, counseling and support.

Program Data

• Since its inception, 359 patients have been enrolled in the program, (29 of them under 20 years old).
• Seventy-seven percent of patients are Latina.
• 11 percent are uninsured.

CHAMP (Chelsea Asthma Management Program)
Wanda Velazquez, Program Coordinator
Elisha Atkins, MD, MS, MGH Chelsea
Eduardo Budge, MD, MGH Chelsea

MGH Chelsea and the City of Chelsea Health Department joined together in 1997 to improve the care management of patients with asthma and to reduce the environmental causes of asthma. Today, the program has four components: patient care management, the NHP program, community outreach and education and environmental changes.

Patient Care Management. The Chelsea Asthma Management Program (CHAMP) identifies patients with asthma, conducts a case assessment and does outreach and follow-up, often in the home. To date, the program has seen more than 371 patients through home and office visits. Fifty percent of those patients have had at least one follow-up home or office visit or telephone call. Fifty-five percent of patients have been referred by their primary care physicians, 25 percent have self-referred, 16 percent have been referred by school nurses, and the remaining four percent have been referred by other sources.

During the home visits the Program Coordinator assesses potential hazards that may exacerbate asthma, gives recommendations on how to eliminate them, and if necessary, advocates to landlords and local agencies for solutions to those problems. The Program Coordinator also teaches patients how to manage their symptoms and medications. The results of the home visit and the medical treatment of the patient are reviewed by the program physicians, and recommendations are made to the Program Coordinator and the patient's primary care providers.

CHAMP encourages and accepts referrals from doctors and nurse practitioners at the health center, and school nurses from Chelsea Public Schools. CHAMP also seeks patients with unrecognized asthma through community education at health fairs and talks to local groups. CHAMP staff conduct educational sessions for Adult Medicine, Pediatrics, Medical Walk-In and school nurses, and have developed ‘asthma boxes’ with educational and monitoring materials for each medical exam room. CHAMP has developed templates for asthma action plans in English, Spanish and Portuguese for the electronic medical record system (LMR), to be printed and given to patients. CHAMP has updated and extended its resources on asthma educational material in different languages and made it available to patients and providers at the health center.

Processes of Care. CHAMP has been evaluated in several ways. In 2003, CHAMP used data obtained from the patient baseline and follow-up assessments to evaluate processes associated with improved outcomes. Processes of care measures include quality of life (as measured by asthma symptom reduction and days missed from school or work), use of asthma controller medications, and indoor environmental triggers. The median time between the baseline and follow-up assessments was six months. CHAMP analyzed behavior change in 50 participants that had a follow-up contact at the time of the analysis. Major findings are:

* The mean number of days for each asthma symptom significantly decreased, including wheezing and coughing), nocturnal symptoms, activity limitations, and changes in daytime or evening plans due to asthma.

* The average number of asthma symptoms experienced by participants dropped 50 percent from baseline to follow-up (2.24 vs. 1.12 respectively).

* Use of asthma controller medications increased significantly.

* Little change occurred in asthma triggers between baseline and follow-up.

* No significant changes in school or work absences.

Another evaluation compared those in the program (the study group) and those who were not (the control group) in regards to urgent care visits, hospitalizations, and physician office visits. The study included 198 patients identified as having an asthma-related physician or urgent care visit or hospitalization during the past 12 months. Each of these study patients was paired with an asthma patient in the Chelsea community who had not participated in CHAMP.
There are several significant findings:

* There was a statistically significant difference in hospitalizations between study and control groups. The study group had a much larger decrease in hospitalizations (66 percent) than the control group (11 percent).

* Patients 19 years and older in the study group had a 57 percent decrease in hospitalizations while those in the control group had a seven percent increase in hospitalizations. These differences were statistically significant

* Patients 19 years and older in the study group had a 31 percent increase in physician visits while those in the control group had a nine percent decrease in physician visits. These differences were statistically significant.

Neighborhood Health Plan and Medical Walk-In Patient Intervention. For the past three years, the program has been contacting patients who are insured by Neighborhood Health Plan, as well as patients who have been treated for asthma in MGH Chelsea's Medical Walk-In Unit. The goal of this follow up with patients is to identify those who are not receiving regular care or are having difficulty controlling their symptoms. The goals of this intervention are to help these patients better manage their asthma, enroll them in primary care and connect them to the CHAMP program. The CHAMP Coordinator calls patients and conducts in-depth assessments of compliance with prescribed medications. The information gained through the interview is compared with the patient’s medical record note. The patient’s management plan is reviewed with the program clinicians and the information is forwarded to the primary care provider with recommendations for an adjustment of medical regimen, as the CHAMP physicians consider appropriate. If necessary, follow-up calls and appointments are made.

Since 2002, more than 800 NHP and Walk In patients were identified (332 in the Fiscal Year 2004). Out of those 332 patients 59 percent (196) are female and 41 percent (136) are male. 27 percent of the patients are below the age of 18 years. 40 percent of these patients received a message or letter from CHAMP notifying them of the program and services, five percent received some type of asthma education over the phone, 19 percent had a letter or report sent to their primary care physician, 80 percent had their case reviewed with one of the physicians who clinically supervise the program.

Community Outreach and Education. CHAMP identifies community education and outreach as important program components. Aside from conducting education and awareness information tables within MGH Chelsea, the program also participates in local health and school fairs. In 2004, CHAMP participated in the Massachusetts General Hospital for Children’s health fair, the Chelsea ROCA’s health fair, the Clark Avenue School health fair, the Chelsea Family Night Out fair, the Summer Safety fair at MGH Chelsea, and a local community church’s health fair. Over 2000 people received information on asthma and asthma management through these various forums.

Environmental Changes. In addition to caring for patients in the doctor’s office and home, CHAMP works with city officials to change the conditions that exacerbate asthma. First CHAMP worked with high school students to plot on a map where pockets of asthma most frequently occurred within the community. A public housing development built on a swamp emerged as a key problem, with several CHAMP patients living in apartments seriously contaminated with mold, an allergen that worsens asthma. Through CHAMP, an environmental consultant was hired to evaluate the development and make recommendations. The consultant documented serious problems of water infiltration leading to conditions ideal for mold growth.

CHAMP assisted the Chelsea Housing Department in obtaining state funding for an ambitious, three-stage project to correct these conditions. The first and second stages, which are completed, include plumbing repairs to reduce water in the basement, ventilation improvements, and barrier installation to prevent flooding into the building. The third stage is currently in process and may include additional measures to reduce moisture, such as a new roof and/or windows, waterproofing the walls, and installing dryer vents. The City has also constructed two playgrounds that will allow children in these developments to get fresh air and exercise outside of the housing development.

CHAMP, the environmental consultant and staff from the Chelsea Housing Department, continue to work together to detect and correct conditions that affect indoor air quality in this housing development. CHAMP continues to support the Housing Department on additional funding requests. CHAMP is also working on new educational material for tenants on how to manage mold and pest problems while permanent repairs are performed, along with developing a seminar for the Chelsea community on indoor air quality and tenants rights.

In June of 2004, the Chelsea Asthma Management Program applied for and received funding from the Massachusetts Department of Public Health to increase reporting on work-related asthma. The proposal was funded for the amount of $12,000. This grant focuses on identifying and reporting work-related asthma cases through review of the Medical Walk-In logs, referrals from physicians and information tables around MGH Chelsea to increase awareness about work-related asthma.

Chelsea High School Student Health Center
Jordan Hampton, CPNP, MSN
Tamara Leaf, Ph.D.
Jennifer Vetree, MSRD
Teresa Grignon, MS, RNCS
Ming Sun, ARCH Program Coordinator
Claudia Dias, Coordinator

The MGH Chelsea High School Student Health Center (SHC) has now completed its 14th year of operation. The SHC is clinically overseen by M. Sheila Desmond, MD, Chief of Adolescent and Pediatric Medicine MGH Chelsea and physician for Chelsea Public Schools in collaboration with the Chelsea Public School system, which continues to be managed in partnership with the Boston University School of Education, with Tom Kingston as Superintendent.

Patient Care Activities
The SHC provides confidential, comprehensive care, including physical exams, reproductive health care, mental health counseling, nutrition, preventive health education, and treatment for acute, episodic and chronic illnesses. All Chelsea High School students are eligible to enroll in the SHC. The SHC staff collaborates with primary care providers and specialists to ensure continuity of care and appropriate follow up. Students may be seen at the SHC between 8:00 AM and 4:00 PM during school days from the last week in August to the last week in June. Students under the age of 18 years old must have signed consent from their parent or guardian to be seen at the SHC. Some of the special services provided by the SHC include classroom presentations on reproductive health for ninth grade health education classes, weekly health education classes at Choice Thru Education (an alternative school for pregnant and parenting teens), GAPPS (Graduation and Attendance for Pregnant and Parenting Students), a program that provides supportive services to this particularly high risk group of students, and sponsorship of the Stay in Shape program which is a project designed to address health, nutrition, and physical activity among female students.

The number of students actively registered to the Student Health Center increased from 340 in 2003 to 375 in 2004. An additional 293 parental consents are on file. The 2004 enrollment numbers represent a ten percent increase from last year. The total number of visits at the Student Health Center in the 2003-2004 academic year was 1792, a 24 percent increase in the total number of visits from last year. This increase was comprised of a 19 percent increase in nurse practitioner visits, and a 39 percent increase in mental health visits.

Visiting Moms Program
Fadumo Hirsi, Visiting Mom
Amal Ali, Visiting Mom
Ricarda Romao, Visiting Mom
Marybeth Bronson, MSW, MGH Chelsea

MGH Chelsea received a three-year grant from the Jessie Ball duPont Foundation to begin a long-term home visiting program for the most vulnerable expectant and new mothers in Chelsea in January of 2002. In December of the same year, the Ladies Visiting Committee of MGH contributed a gift to support this program as well. MGH Center for Community Health Improvement supports the remaining program costs. The program was developed after completing a comprehensive assessment of the needs of low-income women who deliver their babies at MGH, most of whom are immigrants or refugees. These mothers are particularly vulnerable because they have lost much of their cultural framework and many of the parenting techniques traditional to their native cultures are difficult to maintain. The women are referred to the Visiting Moms Program from MGH Chelsea Prenatal, Pediatrics, or Mental Health Units, as well as from the inpatient MGH Boston Obstetrics Unit.

Over the past two years four part time para-professional, bi-cultural, home visitors have been using a relationship-based model of home visiting and support to help mothers, ages 21 and above, adjust to and care for their child. One of the home visitors speaks Spanish, one speaks Somali and Swahili, one speaks Arabic, and one speaks Portuguese and Spanish. Given that the home visitors are bi-lingual and bi-cultural they are better able to influence the mother’s motivation to use resources, some of which the Visiting Moms themselves might have used. The shared language and culture helps to reduce social distance between the home visitor and the mother. The Visiting Mom also serves as a role model, demonstrating ways to adapt to a new country and culture. The overall goal of the program is to achieve stability in order to enable a healthy long-term outcome for the child, the mother, and the family.

Since the Visiting Moms Program began, 81 cases have been opened, with 42 currently enrolled in services. The average age of a mother is 28, with women ranging from 16 to 44 years old (73 percent are under 30 years old). Close to 70 percent of the women are married and close to 52 percent were pregnant when they were referred. Most of the fathers (70 percent) are involved with the children. More than half of the women (56.8 percent) are new mothers, with the remaining having one or more children. However, none of those children were born in the United States, and many remain in home countries with relatives.

Sixty-three percent of the women are from Latin America and the Caribbean (with 50 percent from Central America alone), 25 percent from Africa, five percent from the Middle East, and five percent from the U.S. Collectively the women speak more than ten languages, with the majority speaking Spanish (54 percent) and the remaining divided among Somali, Arabic, Portuguese, Swahili, Ugandan, Dari, Haitian Creole, French and Cantonese. Approximately 75 percent of the women rely on some form of welfare assistance. The majority has less than a middle school education (57 percent), however a minority has nearly completed or completed high school (23 percent), and a few women have attended some college or trade school (10 percent).

The program participants have experienced numerous stressors while adapting to the United States. The five most prevalent ones experienced by at least 70 percent of the women include: lack of finances, unemployment, language barriers, mental health problems, and difficulty accessing benefits. A sizable minority of the families also exhibits excessive arguing, emotional and/or physical abuse of the wife, struggles with divorce or separation, and close family members with serious illnesses. Almost all are separated from extended family and having difficulties balancing work and family needs. According to the Visiting Moms 45 percent of the program participants are mildly to moderately uncomfortable in caring for their infants and seem to lack confidence in the process. Approximately 63 percent are noted to have some attachment difficulties between the mother and baby. In addition, 50 percent of the mothers have minimal or no knowledge of child development and 26 percent only have some knowledge about caring for their babies.

The Visiting Mom develops a supportive relationship with the participating mother, visiting regularly at home, seeing her at the clinic, or offering to attend other appointments with her. She offers emotional support, concrete assistance, advocacy, and referral to resources. The focus of the intervention remains twofold. Of primary importance are the physical and emotional needs of the mother and baby. Secondarily, in order to enhance the functional stability of the family the Visiting Mom will offer many supportive services. The following include some problems addressed by the home-visitor with the services described above: assistance obtaining a crib (78 percent), assistance obtaining a child related item (38 percent), assistance obtaining children’s clothes (48 percent), excessive arguing (22 percent), family violence (21 percent), emotional abuse from partner (33 percent), alcohol or drug use in the family (15 percent), illness in the family (25 percent), financial needs (70 percent), language translation (74 percent), food (28 percent), and unemployment (67 percent). The Visiting Mom is able to maintain these supportive relationships for up to three years. Most of the families so far have used the services for approximately six to twelve months establishing a modicum of stability. At termination many of the mothers have returned to work and have fewer needs for the services of the Visiting Mom.

The following is an example of one of the Visiting Mom’s cases.

At age 20, Halima came alone to this country as a refugee from Tanzania. She arrived here speaking only Swahili and knowing no one. Since her arrival she has learned English. She was undocumented and seeking legal asylum in the beginning, so was not permitted to work. Halima was referred to the Visiting Mom’s Program when she became pregnant by her boyfriend who was also seeking asylum. Halima impressed all those who met her with a smiling indomitable spirit. However the OB staff also saw the desperation of her circumstances. She had no family or friends, feared deportation and relied solely on the small earnings from the baby’s father.

Halima had a difficult c-section delivery. Her baby girl Liza was healthy, but Halima took a very long time to heal. She was anemic and depressed. The threads of attachment to Liza were not taking root through the thicket of anxiety and depression.

The Visiting Mom began weekly home visits. She linked Halima with Welfare, food stamps, and the WIC program. Information about feeding, nutrition and infant development was provided. She also became an emotional touchstone for Halima who told stories of her immigration and of reckoning her fantasy of life in America with the reality. Isolation was mitigated. Halima’s depression diminished. Halima began to notice the Visiting Mom interacting with baby Liza. There was lots of holding, touching and laughter. Tentative at first, Halima began to join in. She then poured forth with a stream of questions about caring for her daughter. Confidence and trust grew. Halima’s attachment to her baby grew strong.

It was then revealed to the Visiting Mom that the baby’s father had become physically abusive to Halima. She felt helpless and dependent, still fearing deportation.

With the guidance of the Visiting Mom, Halima received legal help in her quest for asylum. She was introduced to the HAVEN program for battered women, and separated from the baby’s father. Through Project Rise at MGH she received job training. Halima now has her Green Card and is employed by MGH. With the help and support of the Visiting Mom she has become autonomous and is providing a safer more secure home for her daughter who is thriving.

Food for Families
Yesenia Olivero, Food for Families, Outreach Worker
Katherine L. Flaherty,Sci.D., Research Director, MGH

The goal of the Food for Families program is to improve health status by reducing the incidence of food insecurity and hunger among individuals and families. Food for Families reaches families from Chelsea and surrounding communities whose children are pediatric patients at MGH Chelsea.

Started in 2003 through a study conducted by Ronald Kleinman, MD, current chief of MGH pediatrics, and Michael Murphy, EdD, with funding from Project Bread Project Bread – The Walk for Hunger, Food for Families identifies families in the Pediatrics Department at MGH Chelsea experiencing hunger or who are at risk for hunger through a single validated screening question. Once identified, patients and their families are referred to an outreach worker who assists families with accessing the federal nutrition programs, including helping them complete the application for the Food Stamp Program.

The need for increased access to nutritious food, particularly among Latino residents, is urgent. A 2005 Project Bread-sponsored study surveyed households in 216 census tracts in Massachusetts with high rates of poverty. Overall, 32 percent of households surveyed in these low-income communities reported food insecurity, meaning that they were unable to buy sufficient food to meet the basic nutritional needs of households’ members. Food insecurity was even higher, 37 percent, among Latino households.

Among families screened 11  percent reported experiencing hunger in the past month. Of these, 40 percent carry a nutrition-related diagnosis, such as diabetes mellitus or anemia. Patients with these conditions are at higher risk for chronic health problems when they regularly lack basic nutrition. Prior to the introduction of food assistance in the health center, providers were not aware that these factors were influencing health outcomes among their patients.

2007 Program Accomplishments

• A paper describing the validation of the screening question – “Use of a single-question screening tool to detect hunger in families attending a neighborhood health center” is in process.
• In September 2007,  with support from Partners Community Benefit and Project Bread, the project was expanded to include six additional health center sites. The new sites are: Codman Square Health Center, Dorchester House Health Center, Greater Brook Valley Health Center Lynn Community Health Center, South Boston Health Center and Southern Jamaica Plain Health Center. Effort was expended in getting these sites set up and running and holding various training sessions for outreach workers. 

Program Data

• To date, more than 2,000 families have been screened for hunger, and about 100 families at MGH Chelsea have received assistance securing food resources.

Immigrant and Refugee Health Program
Eric Kamba, MSW, MPH, Refugee Health Assessment Program Manager
Chantal Kayitesi, MPH, Refugee Women’s Program Manager
Adnan Zubcevic, Refugee Program Manager

The goal of the Immigrant and Refugee Health Program is to help newly arriving refugees and immigrants at MGH Chelsea cope with the struggles of everyday life while managing the impact of trauma experienced in their native countries. The program managers provide training to staff in the health center and community in identifying children who may be suffering from the effects of trauma, and work with providers and outreach staff to support children and their parents individually and in groups in culturally appropriate ways. The managers work with parents and families to adjust to their new lives in the US, find jobs, enroll in education, engage in health and mental health services, locate and retain safe and adequate housing, obtain legal help, resolve family conflicts and address family or community violence issues.

The most recent arrivals to Chelsea have been Somali, Congolese, Burundian, Rwandan and refugee groups from sub central Africa both French and English speaking.  The program has also accommodated refugee groups from Vietnam, Myanmar and Eritrea.  Managers continued to provide services to significant numbers of Sudanese, Russian, Bosnians and others from Arabic-speaking countries. The Immigrant and Refugee Health Program provides services in multiple languages through its own staff or other members of the Community Health Team, including Bosnian, Somali, French, Arabic, Russian, Swahili, Dari, Farsi, Pashtu, Haitian Creole, and Portuguese. The program works with patients to develop a comprehensive plan to assure they receive adequate care.
 
A Designated Refugee Health Assessment Site

Through a contract with the Massachusetts Department of Public Health (DPH), MGH Chelsea provides a comprehensive health assessment for newly arriving refugees and persons seeking asylum as required by the U.S. State Department. The assessment includes screening for issues ranging from uncorrected dental or eye problems, to the consequences of torture or malnutrition. Refugee patients may arrive with serious medical conditions including highly contagious pulmonary tuberculosis, malaria, syphilis, chronic hepatitis B and C, and intestinal parasites.  Due to a history of extreme trauma for many refugees, providers screen for mental health issues such as post-traumatic stress disorder and acute psychosis, early in the patient’s care.

The Immigrant and Refugee Health Program provides a continuum of care across multiple sites, including the hospital, home, schools, and early intervention programs. To reduce anxiety and provide information, the program managers make a home visits to inform families about how health care services are delivered in the U.S. MGH Chelsea has developed strong working relationships with Boston-area refugee resettlement agencies including Volags, and the Office of Refugees and Immigrants.

2007 Program Accomplishments

• The program managers conducted psycho-social support groups: a group for elementary-school aged Somali Bantu boys and their mothers that focused on social skills, anger management and self-regulation; a group for refugee girls that focused on building self-esteem; a refugee women’s support group; and a group for Somali teen boys focusing on identity issues.
• Multiple workshops were held for parents on how they can assist their children with adjusting to a new school environment. Many of the parents have never attended school themselves and did not understand school expectations.
• One of the program managers sits on the Governor’s Advisory Board on Refugees and Immigrants.
• Four of the Refugee Health Assessment providers, Drs. Lewis, Carr, Guglietta and the Refugee Program Manager, Eric Kamba received an award from the National Center for Preparedness, Detection and Control of Infectious Diseases for establishing successful partnership and demonstrating scientific excellence in preventing the importation of disease into the United States during an overseas polio outbreak.
• Program Managers helped organize multiple trainings for state and community agencies, MGH social work and psychology interns, and psychiatry residents, as well as helped with orientation for new residents in Adult Medicine. 

Program Data

• Over 1,000 individuals were served by the program at the health center and schools. 
• The managers had over 3,000 combined encounters with program participants where individual counseling, advocacy and case management were provided.
• RHAP provided services to 167 refugees and asylees, including 60 from Somalia, 21 from Burundi , 13 from Eritrea, 13 from Congo, seven from Cuba, six from Vietnam, six from Uganda, five from Haiti, four from Ethiopia, four from Belarus, three from Togo, three from Sudan, three from China, two from Gambia, two from Tanzania, two from Cameroon, two from Liberia, two from Nepal, two from Russia, two from North Korea and one each from Albania, Mexico, El Salvador, Cambodia, and Algeria
• 99 percent of new refugee patients kept their first and second appointments at MGH Chelsea.

Legal Initiative For Kids (LINK)
Laura Maslow-Armand, Lawyers’ Committee for Civil Rights under Law

LINK removes legal obstacles that interfere with the health status of pediatric patients at MGH Chelsea. Under a contract with the Lawyers’ Committee for Civil Rights Under the Law, LINK assists families with maintaining or obtaining safe and secure housing, and gaining access to public entitlements and cash assistance. In the majority of cases, LINK assistance was extensive, involving several hours of consultation, document preparation and advocacy. LINK represented families at eviction hearings in District Court, at eligibility appeals at Boston, Chelsea and Somerville Housing Authorities, at Disability Hearings before an administrative law judge, and argued against termination decisions at the Department of Transitional Assistance.   LINK also works closely with the HAVEN domestic violence program in order to help clients obtain priority status for subsidized housing.

Program Data

• Since its inception in 2003, LINK has assisted over 185 families representing more than 750 family members.
• Also since 2003, LINK has successfully completed helping 28 families move into public or subsidized housing, prevented evictions of 12 families, and obtained disability benefits (SSI or SSDI) for 15 families.

Medical Interpreter Services
Jennifer Beauchamp-Ankeny, Interpreter Services Manager

The goal of the Medical Interpreter Services is to provide quality care to MGH Chelsea patients by reducing language and cultural barriers. Although staff members are interpreters, they also carry out some outreach work. They facilitate accurate communication between patients and healthcare providers, provide a cultural framework that enhances understanding among patients and providers, advocate for patients, and help them navigate the healthcare system. Staff interpreters provide on-site interpretation for patients who speak Bosnian, Spanish, Portuguese, Dari, Russian, Arabic, Somali and Swahili. On-call interpreters are hired as needed, including Sign language interpreters from the Massachusetts Commission for the Deaf and Hard of Hearing.

Continuous improvement is a hallmark of this program. Systems for requesting interpreters are reviewed regularly to ensure consistent and reliable service. In the fall of 2007, the department launched the Toyota Process Improvement Project to streamline interpreter services and ensure quicker and more efficient interpreter services for our patients and providers. Training sessions are being coordinated with the Interpreter Services office at MGH Boston to boost the skills of staff interpreters to a higher level. New measures that will further improve access to interpreting services include off-site videoconferencing and speakerphones in exam rooms that will facilitate the use of phone interpretation when a face-to-face interpreter is not available.

2007 Accomplishments

• The Chelsea HealthCare Center Refugee Health Assessment Program was featured in the Massachusetts General Hospital’s annual report for 2006.  The story focused on M. Javad Rajai, the health centers’ Arabic, Russian and Dari interpreter.
• New Spanish, Portuguese, and Somali interpreters were hired.
• Staff interpreters attended the conference of the International Medical Interpreter Association in Boston, which offered many informative training courses and seminars.
• Some staff interpreters are currently participating in medical terminology courses at MGH and outreach educators training at the Community Health Education Center.

Program Data

• Close to 10,000 encounters were conducted, averaging 776 per month. 
• Over 5,000 of those encounters involved interpreting at medical appointments, of which: 55 percent were in Spanish, 16 percent in African languages (Somali and Swahili), 11 percent in Portuguese, 12 percent in Middle Eastern languages (Dari and Arabic), and six percent in Russian and other Eastern European languages.
• Interpreters performed more than 4,000 outreach and support activities, including telephone calls (39 percent), assistance to patients with filling out forms and applications, written translations of documents (32 percent), meetings with community agencies, home visits, interpretation offsite, and patient navigation (15 percent).

MGH ROCA Clinic
Lisa Carr, MD, MGH Chelsea
Gail Gall, CPNP, MGH Chelsea
Vikki Segovia, Family Planning Counselor, MGH Chelsea

MGH Chelsea operates a fully licensed satellite clinic two evenings a week at ROCA, a Chelsea-based youth development organization. The goals of the MGH ROCA Youth Clinic are to introduce young people to the health care system in an age-appropriate approach to care, to encourage young people to take a proactive role in making healthy life choices by providing access to culturally sensitive health information, and to improve understanding of the health needs of young people.

The clinic uses an innovative approach to engage hard to reach youth in health care by integrating health promotion into the arts, education and leadership programming at ROCA. The clinic provides comprehensive health risk assessments, STD testing and counseling, anonymous HIV testing and counseling, and contraceptive services. A bilingual, bicultural ROCA Family Planning Counselor provides teens with education, discusses relationship issues, and makes assessments for depression and relationship violence. She also provides group education about contraceptives and sexually transmitted diseases to adolescent mothers in ROCA's Healthy Families Program and to young people at La Via, ROCA's school for high-risk youth.  Those young people with identified depression / high risk behaviors are referred to a mental health worker who works directly with the program and can provide counseling and medicine therapy to identified patients within one month of referral.  The MGH ROCA clinic closely coordinates care with both the Chelsea High School Clinic and The Revere Adolescent Clinic.

2007 Program Data

• On average, the clinic serves five to ten adolescents during each of its two evening sessions per week.

Prenatal Outreach Program
Adela Marquez, Outreach Worker

The Prenatal Outreach Program seeks to improve birth outcomes among at-risk pregnant women in Chelsea.  A bilingual, bicultural prenatal outreach worker connects patients with hospital and community resources and assists them with planning for their unborn child and their own health care. The outreach worker helps patients complete forms (such as the birth certificates), provides family planning information, advocates for health insurance and welfare benefits, and connects patients with local food pantries, childcare programs, clothing services, WIC, and English as a Second Language programs. The program depends on many established partnerships in order to fully serve patients, including HAVEN, Mental Health and Social Services, Pediatrics, the Visiting Moms’ Program, the Circle of Care Project for Pregnant and Parenting Teens, (described below), the Safe Start Program and Patient Financial Services at MGH Chelsea. A support group, “My Baby and Me” is conducted in English and Spanish and gives expectant and new mothers the opportunity to share experiences and receive peer support. 

In May 2007, the MGH Chelsea Prenatal Department was awarded a grant from the Massachusetts Department of Public Health to facilitate the provision of community-based services to women of reproductive age. The goal of this project is to ensure that all pregnant and postpartum patients of the health center, especially those identified as high risk have access to the appropriate social support services.  Part of this project includes the implementation of a standardized, valid depression-screening tool called the Edinburgh Postnatal Depression Scale. By administering this scale to pregnant and postpartum patients at their initial, 28 week and postpartum appointments the goal is to identify, evaluate and treat women who have a possible depression.  The role of the outreach worker is to administer the scale at the 28-week appointment. The prenatal social workers connected with this project provide the evaluation and treatment services in conjunction with the Mental Health Department.

A database has been developed to track needs of pregnant and postpartum patients with their needs identified and documentation that these patients were referred to the appropriate services. Reports will be run from this database to gather additional demographic information for the possible development of future programs.

Program Data

• The Prenatal Outreach Worker worked with over 280 patients throughout their pregnancy & post-partum period.  
• The majority of patients were undocumented, did not speak English and had very low literacy levels in their native languages. 
• Patients ranged in age from adolescence to midlife, and most were single and unemployed.

Reach Out and Read
Kathleen W. Healey, CPNP, MSN, Director
Margaret Johnson, Coordinator

Since 1997, MGH Chelsea has promoted family literacy through Reach Out and Read (ROR) by providing quality children’s books in the Adolescent & Pediatric Medicine waiting areas and exam rooms.  A review of the program demonstrated that parents are more aware of the importance of reading to their children as a result of the program.

2007 Program Accomplishments
In 2007, ROR has incorporated literacy into MGH Chelsea’s Summer Safety Fair through a “Reading Corner” as well as has participated in the Chelsea Library Literacy Fair, “Chelsea Reads”.

Program Data
Since it began in 1997, the program has distributed over 50,026 new and used books.

Refugee School Program
Ali S. Abdullahi, Refugee School Program Coordinator

The Refugee School Program was launched in spring 2007 and is intended to bridge the cultural and academic gap for newly-arrived school-age African children. The program is funded jointly by MGH Center for Community Health Improvement and the Chelsea Public School System.  In 2007, a special grant was received from the MGH Ladies Visiting Committee to help support the launching of the program. 

The Refugee School Program Coordinator works closely with the Community Health Team, Pediatrics and Mental Health and with school social workers, teachers and administrators in the seven public schools in Chelsea, the Parent Information Center and the Head Start Program.  The program coordinator assists with school registration, enrollment, problem solving, guiding students to select suitable subjects, educating teachers about different cultures, defusing classroom tensions, providing after-school help for students and coordinating parent/school meetings and helping in those meetings with interpretation.

The program also works closely with parents, raising their awareness of the importance of education, since most parents were not exposed to formal education in their homelands.  The coordinator works to get parents involved in their children’s schooling, facilitating their connection to the educational institutions and persuading them to initiate meetings with school staff when necessary.  The coordinator also encourages school staff to make the school environment hospitable for disinclined parents.

The coordinator explains to students what rights and responsibilities the have in relation to school including educating students about the culture in the United States, the school’s expectations, the importance of education, the importance of setting future goals and possible venues to attain and accomplish these goals.  The coordinator counsels students against falling pray to peer pressure and joining and participating in gang related activities.  The coordinator also makes referrals to appropriate community institutions for intervention and assistance for students as parents as needed.  The coordinator keeps an open door policy for all refugee students and encourages them to drop in no matter how trivial the matter is.

Program Data
The program intervenes with an average of seven students per day working closely with parents and school staff. 

Tuberculosis Follow-up Clinic
Tereza Lesiak-Seleznev, RN, MGH Chelsea

Chelsea has the highest rate of TB in the state, but patients find it difficult to adhere to treatment of a latent disease without active symptoms. With the assistance of the DPH, MGH Chelsea operates a clinic for patients with TB on Saturday mornings, a time less likely to conflict with childcare, school, or work responsibilities.  Because the treatment medication must be taken over a six to nine month period and can cause side effects, effective communication with TB patients, who are often immigrants and may not speak English, is essential. A multilingual clinic nurse reviews patients’ adherence, calls patients who fail to keep appointments, monitors for side effects, and gives free medication.

2007 Program Data

• 479 patients have been treated in the clinic since it began in 2003.
• Over 350 patients have completed their treatment.

Mental Health Services in BPS (Charlestown)
D. Scott McLeod, PhD, Director of Child and Adolescent Mental Health Services

The Child and Family Team of the Counseling and Behavioral Services Unit of MGH Charlestown provides a range of services to Boston Public Schools in Charlestown, including the Warren Prescott and Harvard Kent Elementary Schools and the Clarence Edwards Middle School, as well as to the Head Start Program, operated by the John F. Kennedy Center.  The team also consults with the staff of the Boys and Girls Club. 

In the schools, psychologists, social workers, and fellows provide therapeutic and consultative services.  Specifically, they consult with teachers, administrative staff and Student Support teams and provide direct therapeutic services to students and their families.  Clinicians regularly attend Individualized Educational Plan meetings. 
The Team provides school-based services for multiple reasons: to reach out to children and families who are less likely to seek services at the Health Center for fear of stigma; to accommodate parents and guardians who have difficulty getting children to clinics at all; and to help children whose primary problems are school-based.  When school is not in session, students and their families are offered services at MGH Charlestown, or, if necessary, in their homes.  For the second consecutive year, providers have added eight time-limited psycho educational groups at the Edwards Middle school.  These groups are intended for students who are at risk for engaging in violence and other risky behaviors. 

This year, the new principal at the Charlestown High School has initiated dis