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 Community Benefit Program 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.

Boston Health Care Post Secondary Support Initiative

MGH, Brigham and Women’s Hospital and the PIC have designed a model for providing post-secondary transition support to BPS graduates who have demonstrated an interest in health care or health care management careers, and who will be pursuing post-secondary certificates or degrees in the Boston area. Most recently, Beth Israel Deaconess Medical Center has joined this collaborative. Boston’s Health Care Post-Secondary Support Initiative is designed to address two critical issues:

• The decreasing supply of workers in the Boston labor market, simultaneous with increasing demand for culturally competent health care professionals
• The need for coaching, financial planning and support, and to successfully apply to and complete post-secondary health care certificate and degree programs

Many of the program applicants have demonstrated success through previous employment experiences at MGH either through ProTech or the J4Y programs. The participating students may apply for part-time jobs at MGH, and receive academic support, assistance with financial aid applications, peer support, and career workshops.

2007 Program Data

• Currently, a total of 35 students are enrolled in the program, 18 of these program participants and/or graduates work at MGH while pursuing their college degrees.
• Since PS HealthCare's inception in 2004, five students who were participants in either the MGH ProTech Program or Summer Jobs for Youth have been accepted into nursing programs; two have been accepted into MA College of Pharmacy's Pharmacy Program; one has earned her Critical Care Technician certification; one has been accepted into a Social Work program; one is enrolled in pre-medical imaging courses; one is studying pre-medicine and one graduated from the City Lab Academy Program at Boston University. Other students have applied for admission into other health related programs and at the time of the publication are waiting to hear from admissions offices.

Bridge to Advance Science Program

In the summer of 2006, MGH worked with BPS to launch the Bridge to Advanced Placement Science Program, which seeks to increase enrollment, support and success in advanced placement science classes. The program’s objectives are to:

• To increase the number of students enrolling in AP Science courses
• To increase underrepresented minority participation in AP Science courses
• To better prepare students for success in AP Science courses
• To improve test scores in AP Biology, AP Chemistry, AP Environmental Science, and AP Physics courses

In addition to BPS and MGH, the partners for this program include PIC, Harvard Medical School, Northeastern University, UMass Boston, the College Board, and other school districts in the greater Boston area. Through the program, students receive an intensive introduction to the AP curriculum and an opportunity to “accelerate learning” in deficit areas, have individual tutors, take practice AP exams, and participate in monthly lab activities in a university setting. Students also participate in internships in area institutions that relate to their AP science class. The program provides support to AP science teachers, through monthly meetings in which the teachers share ideas and resources, discuss challenges and strategies, and hear from guest speakers. The program is funded by the STEM Pipeline Fund.

2007 Program Data

• Twenty East Boston High School seniors who were in ProTech and the J4Y program participated in the program, receiving paid instruction in AP Biology, and a paid summer job at MGH.
  

Child Protection Consultation Team
Susan Lipton, LICSW, Program Director
Alice Newton, MD, Medical Director

The mission of the Child Protection Consultation Team (the Team) is:

To provide the highest standard of care to children who may have experienced or are suspected of experiencing abuse or neglect and their families; and to provide all clinicians who care for children with the basic skills and knowledge necessary to provide the full range of appropriate support and service to children and their families: i.e., screen, identify, assess, intervene, refer, and follow-up on suspected cases of child abuse and neglect.

The Child Protection Consultation Team provides leadership to the MGH’s response to issues of child abuse and neglect. The Team is comprised of a Program Director, Medical Director, part-time Clinical Social Worker and part-time Pediatrician. Consultation from the Team is available to providers throughout MGH, twenty-four hours a day, seven days a week, to assist with the assessment and management of suspected cases of child maltreatment. Requests for consultations come from Pediatrics, the Emergency Department, Obstetrics, HAVEN, Adult Medicine, Mental Health, MGH health centers in Charlestown, Chelsea and Revere, the West End Clinic, and other MGH and community providers.

The Team works closely with many disciplines and departments within MGH, including clinical social workers, physicians, nurses, HAVEN advocates, psychiatrists, Police and Security, and attorneys. In addition, the Team interfaces with multiple community agencies including the Massachusetts Department of Social Services (DSS), local police departments, district attorney offices, and the courts. The Team also participates in multidisciplinary interagency committees, including the Suffolk County Children’s Advocacy Center and its Advisory Board; a committee that has developed Guidelines for Mandated Reporters Responding to the Co-occurrence of Domestic Violence and Child Abuse and is now developing a statewide training initiative for its implementation by DSS staff and community providers; and a committee that is looking at hospital based child protection teams across the state.
The medical director participates in the Violence Committee of the Massachusetts Medical Society, continuing efforts in the development of a Shaken Baby Syndrome awareness and prevention initiative in Suffolk County, and advocacy for statewide legislation on child abuse prevention. 

• The Team provides interdisciplinary training to staff, on the medical and psychosocial aspects of child maltreatment, in a variety of educational forums throughout MGH and the community. Outreach and training to staff of all disciplines continues to be a major priority for the Child Protection Consultation Team
  
  2006 Program Data
  
  
• The Team provided consultations to clinicians in more than 600possible cases of child abuse and neglect during the last year.
• Reports of suspected child abuse and neglect were filed with the Massachusetts Department of Social Services on behalf of children in fewer than 50 percent of these cases.

Circle of Care
Danelle Marable, MA
Elizabeth Miller, MD, PhD

The Community Benefit Research and Evaluation Team evaluates the Circle of Care project, a partnership between ROCA, a community-based youth development organization, and MGH, providing services to pregnant and parenting teens in Chelsea and Revere.  The Circle of Care project is in its third year of a five-year demonstration grant awarded by the Office of Adolescent Pregnancy Programs, an office of US Health and Human Services.  Services provided include home visiting, parenting skills development, family support, accessible adolescent-focused clinical care, mental health, education, employment training and placement, and referrals to other services.  The goals of the project are to reduce the number of rapid (within two years) repeat pregnancies, support teens to finish their education, and provide opportunities for teens to increase their connectedness to peers and family.  The evaluation aims to measure the impact of the Circle of Care project on a range of social and clinical variables, and to assess how wrap-around services and coordinated care and tracking contribute to the overall success and health of young parents and their children.

The evaluation is a quasi-experimental design, with a comparison group from a neighboring community.  Participants of the evaluation (intervention and control) are asked a series of questions when they enter the evaluation, and then again at six, 12, and 24 months in order to determine the effectiveness of the Circle of Care project.  In addition, participants in the intervention group are interviewed after 12 months to gather their feedback on the Circle of Care project, including what they would like to see added to the project.

There are currently 40 young pregnant and parenting teens involved with the Circle of Care and its evaluation, five of whom are fathers.  The average age of the mother is 16.5 years, while fathers tend to be older, averaging 19 years of age.   Most continue their education, with 65 percent either in school or completed school or a GED program.  More than half (53 percent) are working.  All of the fathers and 89 percent of mothers have had a physical in the past year.  One-quarter of the fathers and 57 percent of mothers have had a mental health screening.  One repeat pregnancy was reported this past year.

Those Circle of Care participants who were interviewed after 12 months indicated high satisfaction with the project, especially with their home visitor and the groups they attend.  As of yet, there have not been enough data collected to determine the long-term effectiveness of the program. 

HAVEN
Ann Daniels, MSW PhD Executive Director, Social Service Department
Bonnie Zimmer, LICSW, Director, HAVEN

Mission and Goal

HAVEN works as part of the broader movement to end intimate partner abuse by improving and enhancing our health care response to MGH patients, employees, and community members who have been impacted by abuse.

HAVEN’s goal is to reduce the immediate impact of violence on survivors and their families, and to help individuals and families seek lives free of violence and abuse. MGH HAVEN serves patients and employees, including the MGH health centers.  HAVEN also trains and consults with MGH providers and other caregivers to screen, identify and respond empathically to survivors of abuse.  In addition, HAVEN advises the hospital on the development of domestic violence policy and protocols, in keeping with guidelines set forth by the Joint Commission.

HAVEN Services and Activities

Advocacy

HAVEN provides welcoming, affirming advocacy and supportive services to all survivors, beginning in the dating years through later life, through a culturally diverse and linguistically supportive array of services.

HAVEN provides ongoing individual counseling and advocacy services to survivors identified by MGH and health center providers, or who self-identify. HAVEN helps survivors understand that they are not at fault for the abuse they suffer, that they are not alone but rather are joined by many others who share similar experiences, and that there is help available both at MGH and in their communities. HAVEN helps connect survivors to needed services, provides information and referrals relating to the legal aspects of domestic violence, and if needed accompanies survivors to health care, legal or other appointments. In order to respond to an especially urgent and violent trend of increased sexual assault and trafficking in our communities, HAVEN has broadened its framework of domestic violence in order to respond to victims in these complex circumstances.

HAVEN is committed to delivering culturally and linguistically appropriate services. Four of the six HAVEN staff are multilingual and provide services in French, Spanish, Haitian Creole and English. Printed program materials are available in English, Spanish, and Khmer.

With the ongoing support of State Street Global Philanthropies, HAVEN has hired a training and prevention coordinator to update and enhance HAVEN’s training capacity, and to explore opportunities to expand our prevention efforts with adolescents and youth in our communities. 

Specialized Adolescent Services

With funding from the Massachusetts Office of Victim Assistance (MOVA), HAVEN continues its innovative adolescent health work. A HAVEN advocate provides services to all patients of the Adolescent Health Clinic at MGH Revere. Also in Revere, a “Healthy Relationships Working Group” comprised of school, health and community partners coordinates services to students and training initiatives. HAVEN participates in Teen Dating Violence Awareness Week and Health Education Outreach to eighth grade students in Revere middle schools. A brochure on healthy relationships and dating violence, developed by an MGH Revere HAVEN advocate and teens has been widely distributed in Revere as a way to outreach to Revere youth. HAVEN recently had the opportunity to train nurse practitioners statewide in some of the techniques developed through this innovative work.

Health Professions Education

HAVEN helps prepare new health care providers through its active internship programs with graduate programs in the Boston area.  Interns assist with client work, facilitate support groups, and conduct research initiatives and other individually designed projects.  This year HAVEN added Tufts University School of Medicine and Suffolk University’s Masters Program in Women’s Health as new educational collaborators.

New Educational Initiative

This year marked HAVEN’s tenth  anniversary at MGH.  The program launched a focused educational and outreach campaign entitled,  “Is Your Relationship Affecting Your Health?”  This innovative brochure, developed with funding from an MGH Making A Difference Grant, and informed by focus groups of providers and consumers,  features checklists, questionnaires, helpful hints, and quotes from survivors. The brochure is available in English and Spanish and helps readers explore questions such as: “Is my relationship healthy... or not?” “How could my health be affected?” “What about my children?” and “Who is Affected?” Another section entitled, “Are you a health-care provider?” offers information about the health impacts of intimate-partner abuse, tips for screening and responding to patients who disclose abuse, referring and consulting with the HAVEN program and how to request staff training, which HAVEN offers throughout the hospital and health centers.

Research and Evaluation

HAVEN uses evaluation to make needed improvements to its programming. HAVEN participated in a study funded by the Agency for Healthcare Research and Quality to validate a new DV Program Client Feedback Form and this year began using the form in clinical work with plans to analyze the data to study program outcomes. HAVEN and the MGH Gillette Center for Women’s Cancer completed a groundbreaking study on a the impact of domestic violence on cancer treatment this year.  The study, funded by the National Cancer Institute, involved in-depth interviews in English and Spanish with patients who have faced cancer while in an abusive relationship. Findings are being analyzed and will be used to educate oncology providers about the impact of domestic violence on cancer treatment and will inform domestic violence guidelines for use in oncology clinics.  HAVEN continues to participate in the dissemination of information gathered through our collaborative research with Dr. Liz Miller of the University of California, Davis.  

Partnerships

HAVEN maintains numerous partnerships in the service of our clients. The Hospital Project of Greater Boston Legal Services, funded through the U.S. Department of Justice, provides legal services to eligible HAVEN clients. HAVEN is an active member of the Conference of Boston Teaching Hospital’s Domestic Violence Advisory Council, the Chelsea and Revere Domestic Violence Task Forces, and SAGE-Boston. HAVEN is also represented on the NASW Committee on Domestic Violence and Sexual Assault, and the Revere School-based Health Center Advisory Committee.  HAVEN is an active member of Jane Doe, Inc., the Massachusetts Coalition against Sexual Assault and Domestic Violence.

Program Data

• Since 1997, HAVEN has provided services to 4,057 patients, employees and MGH visitors.
• During this time, HAVEN has offered over 3,700 consultations to clinicians.
• 34 percent of overall program clients identify as Latina, 10% Black, 5% Asian, 45% White and 6 percent other.  Forty-one percent of HAVEN clients are between the ages of 20 and 39, 43 percent between 40 and59 with 9 percent under the age of 20, and 7 percent over the age of 60.  96 percent of clients served were female. 
• Services were provided in languages other than English (Spanish, French, Haitian Creole) in 24 percent of client contacts

MGH/East Boston High School Partnership
Galia Wise, Program Manager

ProTech Program

For more than 15 years, the MGH has participated in ProTech, a School-to-Career program through the Boston Private Industry Council (PIC) that provides work-based career preparation for high school juniors and seniors interested in possibly pursing careers in health care.  MGH and the MGH Community Benefit Program established the Edward M. Kennedy Health Career Scholarship to support and encourage outstanding ProTech graduates’ entry into post-secondary institutions, particularly in the areas of health care.

Every year, 12 new ProTech interns are identified through a competitive selection process. There are a total of about 24 ProTech interns at any one time. They are then employed over a 20 month period in hospital departments, including Patient Care Services, Pharmacy, Radiology, Nursing, Research, Pathology, and the department of Medicine. In addition to their work experience, ProTech interns participate in mandatory trainings, and professional development seminars. In addition, MGH sends speakers to East Boston High School to present on a variety of health and career topics, hosts student tours of the hospital, and participates in the National Groundhog Job Shadow Day.

2007 Program Data

• Two ProTech interns received the Edward M. Kennedy Health Career Scholarship.
• Nine interns graduated from the ProTech program and were all accepted into post-secondary institutions.
• Two graduates were recipient of the prestigious POSSE Scholarship.
• One intern was admitted to University of Pennsylvania’s Nursing program on a full scholarship.
• Five of the nine graduates have been hired as permanent employees of MGH and continue to work part-time while pursuing their college degrees. 
• Eight of the nine graduates have expressed an interest in pursuing a health related field.

Classroom at the Workplace Program
MGH has participated in the PIC’s Classroom at the Workplace Program (CWP) for the past six summer.  MGH provides jobs, including paid time to attend academic instruction for those who have not yet passed the Math and/or English portions of the MCAS, the state's standardized test required for high school graduation.

2007 Program Data

• Seven East Boston High School juniors and seniors participated in the program with a 92 percent average attendance rate and an 86 percent retention rate.
• Overall, program math scores increased an average of 10.5 percentage points between pre and post test, and English/language arts scores increased an average of 39.8 percentage points.
• Historical program success (2001-2006):73 percent of participating students passed both the English and Math MCAS tests, and an additional 21 percent passed either the English or the Math test.

Health Careers Academy

Health Careers Academy (HCa), a Boston charter school in the Fenway, joined School Partnerships in 2005 through an initiative spearheaded by the Massachusetts Physician's Organization (MGPO) and MGH Patient Care Services (PCS). Students from HCa participate in the ProTech Program, Job Shadow Day and the summer jobs program.

The partnership between HCa and MGH began when Chairman and CEO of MGPO, David Torchiana, MD, served as "Principal for the Day" at the school in 2005.  The MGPO and PCS also fund an annual scholarship program for HCa students.

2007 Program Data

• Six HCa students were selected to join the ProTech program
• Ten students shadowed at MGH during the annual Job Shadow Day, five of them were hosted by MGPO physicians
• Eleven HCa students participated in summer jobs
• Two CPR courses, sponsored by MGPO and PCS were administered to 36 HCa faculty and staff

Summer Jobs for Youth (J4Y) Program
As the city’s largest health care employer, the MGH recognizes its responsibility to provide meaningful employment opportunities to Boston’s youth, and is the city’s largest provider of summer jobs in health care to young people. Since 1991, MGH has provided Boston youth, including students from East Boston High School, Timilty Middle School, and the Health Careers Academy, part-time (25 hours per week) summer employment throughout the hospital as well as the Revere and Chelsea HealthCare Centers. Students go through a rigorous hiring process, and participate in professional development workshops about future careers, particularly in health care. Supervisors also receive a program orientation and training on how to work with youth.

2007 Program Data

• MGH employed 196 high school students, 153 of whom were from Boston.
• Following the 2007 summer jobs program, 17 Boston youth (including ProTech interns) were hired into part-time positions at MGH.

MGH/James P. Timilty Middle School Partnership
Valeria Lowe-Barehmi, Principal
Susan Berglund, Manager, MGH/Timilty Partnership

MGH has been a partner of the James P. Timilty Middle School located on historic Fort Hill in Roxbury since 1989. The goal of this partnership is to improve the academic performance and expand the career horizons of the more than 600 Timilty students through programming with students, teachers, administrators, and families working in partnership with MGH scientists, physicians, and staff.

Science Connection and Science Mentoring Program

The Science Connection Program, funded by the Howard Hughes Medical Institute from 1994-2007, forms the core of the MGH-Timilty partnership. The goals of this program are to increase science literacy, enhance student interest in science/health careers and to create opportunities for students to interact with positive role models and mentors.
Mentors from a variety of departments including nursing, pharmacy, environmental services, respiratory care, nutrition, biomedical engineering and research, meet with Timilty students Friday mornings from October to February at MGH. Students work with mentors to decide on questions that can be answered through an investigation. Mentors guide students in setting up experiments, documenting observations, collecting and analyzing data and preparing oral presentations. All students in the school are required to participate in a school-wide, week-long science fair.  Last year, 69 MGH volunteers, parents, community members and BPS staff judged this fair, enabling every student to be judged twice. Over 65 percent of the judges were MGH/Partners employees. Partners HealthCare provided shuttle buses each day for the judges.

Two Science Family Activity Nights were held at the Museum of Science (MOS) this year. The first event entitled “Who Wants to Be a Neuroscientist?” drew a crowd of more than 250 students, staff and family members. For 14 percent of the families this was their first visit to the MOS. The second event, held in April, focused on the Darwin exhibit and natural selection. This event attracted another large group of 250 with 19 percent of them indicating that they had never been to MOS before.

2007 Program Data

• Twenty-nine students were paired with 38 MGH mentors and co-mentors from 34 departments through the Science Mentoring Program.
• Sixty-nine MGH staff, school volunteers, parents and community members served as judges in the school-wide Science Fair.
• Thirteen Timilty students represented their school at the Boston Regional Science Fair, where eight projects won awards. Four of the winners were mentored by MGH staff. Seven students competed at the Massachusetts State Science Fair where a mentored student won a third place award.

Professional Development and Curriculum Support

The MGH program manager, an experienced science teacher and teacher trainer, provides professional development and curriculum support for science teachers at the school through weekly grade level curriculum sessions and science department meetings. During grade level meetings the support focuses on science content, pacing and classroom management. The department level professional development sessions focus on state and district level assessments, differentiating instruction, strategies for asking open-ended questions, and methods for embedding the Massachusetts Technology/Engineering frameworks into science lessons. Results from the 2007 administration of the Massachusetts Comprehensive Assessment System (MCAS) Science and Technology exam showed improvement in student achievement. The percent of eighth grade students who passed the science test increased from 56 percent in 2006 to 69 percent in 2007.

Science in the Classroom

In collaboration with the MGH Institute of Health Professions (IHP), Science in the Classroom  brings students from the MGH IHP doctoral program in Physical Therapy to present science lessons to the Timilty students. Each lesson addresses state and local science standards for Human Body Systems and enhances the unit of study being taught by the classroom teacher. Lessons include fitness activities in the school gym, data collection and written reflections. During the 2006-2007 school year IHP students implemented the STEP UP Program, an obesity awareness program with 100 Timilty sixth grade students. Each student was given a pedometer and a piece of exercise Theraband to continue the fitness activities at home. Results presented by the IHP indicated that 87percent of the 6th grade students reported increased activity levels at the completion of the program.   Additionally, the IHP group reached the following conclusions: “that the utilization of a structured and concurrent classroom and gym program is effective at raising health awareness and promoting physical activity over a three month period in minority children.”

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

The goals of the Community Medicine Experience 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 to 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 served by a community program. 
The experience takes place during Ambulatory Care Rotation (ACR). Primary care residents and categorical residents spend time at community sites once or twice a week.  So far, over 120 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. Eight to twelve residents are involved in a community medicine rotation every month.

In 2005-6, the majority of residents who participated in the community medicine experience were surveyed.  Eighty percent of residents reported that community medicine met their expectations and 95 percent reported their overall experience as good, very good or excellent.  Ninety-eight percent of residents reported that community medicine was either very or extremely important to their residency training.  In addition, residents were asked about their perceived understanding of model community programs in underserved communities before and after being a part of the community medicine experience.  Their reported understanding of community assessment increased by 28 percent, their ability to define a community increased by 15 percent and their understanding of diverse populations increased by five percent after doing the community medicine experience. 

The survey also asked about their perceived understanding of community medicine with regard to specified health topics.  Their reported understanding of HIV increased by 18 percent, hepatitis C 34 percent, women’s health 17 percent, adolescent medicine seven percent, prison medicine 61 percent, homeless population 25 percent and domestic violence 17 percent. After being a part of the community medicine experience, the residents’ perceived understanding of the social determinants of health increased by eight percent, while their knowledge of model community programs increased by 32 percent and their knowledge of developing or initiating a community project increased by nine percent.

The program was presented at two annual medical conferences on residency training recently, and has submitted a manuscript on this subject to the journal Academic Medicine.

Intern Orientation

At the beginning of the academic year, the incoming medicine interns participated in the third Intern Community Orientation Day during their orientation weeks in June. All of the 60 residents (categorical and primary care) participated in the day. The residents traveled to different community health centers and/or community medicine sites with senior residents and faculty to learn about the community and the resources available for their patients. They also learned about the MGH Community Benefit Program and about the demographics of Boston’s communities. The feedback from the residents has been very positive, and the majority (over 90 percent) thought the day exceeded their expectations.

Community sites have included:

• Boston Health Care for the Homeless, including the Barbara McInnis House, St. Francis House and Baycove 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 House and 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 HIV/Hepatitis C Clinic
• Planned Parenthood League of Massachusetts (PPLM)
• AHOPE Needle Exchange Program

MGH Senior HealthWISE
Barbara E. Moscowitz, MSW, LICSW, Program Director

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 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 MGH and at community sites in both the West End and Beacon Hill Neighborhoods.  All programs, both within MGH and in the buildings and community, are available at no cost.

Partnerships and Activities

Senior HealthWISE collaborates with numerous partners within MGH to deliver its program and services, including the MGH Senior Health, and the Departments of Social Services, Patient Care Services, Patient Financial Services, The Volunteer Department, and the Institute of Health Professions. The MGH General Store and Department of Nutrition and Food Service lend strong support to HealthWISE by providing discounts to members at all MGH and Yawkey gift shops and food sites. The MGH Transportation and Shuttle services has provided transportation to and from volunteer sites such as the Pine Street Inn.

As the needs of frail older adults who are aging in place increase, HealthWISE community partnerships are becoming more structured in order to maximize the effectiveness and delivery of support services.  Older adults are frequently lost in the maze of services and programs, and HealthWISE is committed to active outreach and partnerships with Boston Senior Home Care, Action for

Boston Community Development, the Boston Commission for Elder Affairs, the SHINE program and Match-Up Interfaith Volunteers. Participation in local community efforts and planning is a priority for the program and staff regularly attend committee and program meetings at local social service agencies.

Wellness Centers

Many frail adults become disconnected from available healthcare services because they are overwhelmed, confused, or intimidated by complicated systems.  The goal of the Wellness Centers 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 any other applicable community resources.  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 groups. 

The Wellness Centers have been open for five years, and meet weekly for up to three-hours 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. Residents receive care at Brigham and Women’s Hospital, the Veterans Hospital, New England Medical Center, Boston Medical Center, and others, in addition to MGH. An equally important function of the Wellness staff is to provide consultation to the building managers as they manage the daily challenges of their residents.

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

• Screenings: Memory loss, blood pressure, cholesterol, depression
• Chronic Disease Management: Hypertension, diabetes, arthritis
• Education: Explanation of lab results, medication issues, sleep difficulties, nutrition questions, exercise
• Acute Management: Anxiety, chest pain, cellulitis, gait instability, leg edema, wound evaluation, sudden onset of confusion, flu, fever.
• Home Visits: Per request of building management, or as requested from residents, staff will visit residents unable to leave apartment. Individual may be acutely ill and require hospitalization, or recently discharged from hospital and in need of assistance coordinating care. While some visits may result in a necessary admission to the hospital, intervention and coordination with the resident’s health care provider often prevents hospitalization and additional crisis.

Resource Coordinator and Social Work Visits

Assistance by both professionals is provided to assist residents with information regarding community resources, insurance questions, Medicare Part D information and enrollment, medical escort services, and linkage to critical community partners, such as Boston Senior Home Care.

Senior HealthWISE has had the recent addition of a clinical social worker who in a very short period of time has assisted building managers with suicidal and depressed residents, those as risk for self-neglect and in need of protection, and with adults who are struggling with the clinical condition of hoarding. If untreated and unassisted, many of these individuals are at risk of eviction from their homes. As availability of staff in buildings is increased, there is a clear increase in request for service and intervention.

Bereavement Services. In recognition of the many deaths of residents in Senior Housing, the Social Work and Resource Coordinator team has begun to provide periodic Bereavement Services in buildings where residents can memorialize the deceased, and also support each other as they manage the multiple losses in their lives.

Resident At Risk Program

The Resident at Risk (RAR) Program identifies residents who face serious obstacles and challenges to their independence, and staff maintains frequent and continuous involvement with both Wellness Center and Home Visits, and frequent communication with building management and community providers. In 2007, there were forty new referrals to the RAR Program.

Community Programming

In an effort to respond to the every growing request from seniors in the West End, Beacon Hill and beyond who do not have access to the Wellness Centers in the three sites, HealthWISE has expanded its health and wellness lectures, workshops, exercise classes and social opportunities to all seniors in the community.

HealthWISE also sponsors monthly health screenings and workshops at Hill House, the West End Library and the West End Civic Association. 

Partnership with the Clubs at Charles River Park

Senior HealthWISE partners with the Clubs at Charles River Park to provide discounted class ticket fees, as well as a free monthly exercise program, catered lunch and health education session. The program has become integral to many and has reached capacity of 25 at each class.

To respond to the request and need for additional exercise opportunities, HealthWISE members are now invited to attend free weekly Tai Chi classes. To date, the response has been enthusiastic.

2007 Program Accomplishments

• Growth of Exercise program to include Tai Chi
• Boston Community Boating Invitation to HealthWISE members to experience sailing with instructors
• Growth of CAREWISE Volunteering efforts to include Holiday Toy Drive for the Home for Little Wanderers, hand crafted pillows for donation to hospitalized children, and volunteer time at the Pine Street Inn.
• Development of opportunity with MGH Volunteer Department for seniors to be trained for ‘episodic volunteer opportunities.’ It’s a new concept for the hospital, and provides many seniors with opportunities to have social experiences without commitment to a regular schedule.
• With instruction from the Grub Street Writers, Boston’s premier independent writing center, HealthWISE sponsored three successful memoir writing workshops and will continue to add additional classes.
• HealthWISE staff received training and were certified to lead groups in Chronic Disease Self Management. Planning is underway to begin workshops in each building.
• Lecture topics included: Understanding Brain Aging, Parkinsons, Living with Arthritis, Aging Successfully, Heart Disease In Older Women, Learning about Skin Cancer, Fall Prevention, Atrial Fibrillation, and Understanding Pneumonia in Older Adults. Attendance at lectures ranges from 25 to 40 individuals.
  
  2007 Data
  
  
• Total HealthWISE membership grew from 510 in 2006 to 618 in 2007
• 182 HealthWISE members in Blackstone, Amy Lowell and Beacon House participated in the services of the building Wellness Centers.
• Over 350 flu shots were given free of charge to residents of the buildings and to community members. 

The MGH Committee on Racial and Ethnic Disparities in Health and Health Care
Joseph R. Betancourt, MD, MPH
Joan Quinlan, MPA

In late 2002, Mayor Thomas Menino convened the Boston teaching hospitals to explore their role in eliminating disparities in health and health care among racial and ethnic minorities in the city. These disparities are well documented nationally and locally. As part of that effort, Peter Slavin, MD, President of MGH, created the MGH Committee on Racial and Ethnic Disparities in Health Care (the Disparities Committee) in the spring of 2003, and charged it with identifying and addressing disparities wherever they might exist at MGH. The committee is co-chaired by Dr. Joseph Betancourt, a senior research scientist in the MGH/Partners Institute of Health Policy, and a member of the Institute of Medicine’s (IOM) committee that produced Unequal Treatment, a definitive look at health disparities in America, and Joan Quinlan, Director of the MGH Community Benefit Program. In 2005, MGH announced the formation of the Disparities Solutions Center, directed by Dr. Betancourt.
The Disparities Committee, comprised of senior leaders from throughout the hospital and physician’s organization, formed subcommittees and launched an ambitious agenda. Below is a summary of accomplishments.

Quality Subcommittee

Charge:To develop methods for ongoing quality measurement of outcomes stratified by race and ethnicity and to design quality improvement initiatives to address when issues are identified.

Projects and Accomplishments

Disparities Dashboard. The Disparities Dashboard, first published in 2006, provides patient demographics and utilization, data regarding interpreter services, clinical quality measures for both inpatient and outpatient services by race/ethnicity, and patient experiences with care for different racial and ethnic groups.  Work for the second iteration of the Dashboard is now underway.  The Dashboard is produced under the direction of Gregg Meyer, MD, Msc, senior vice president for quality and safety and Elizabeth Mort, MD, MPH, director of Clinical Care Management and Decision Support, with Sarah Lenz, Senior Project Specialist of the Clinical Care Management Unit, and Amy Giuliani, MPH, Team Leader for Data Analysis and Reporting, among others.  Robin Weinick, PhD, of the MGH Institute for Health Policy, was instrumental in the initial design of the dashboard. 

Medical Policy:. On May 3, 2006, The Medical Policy Committee, upon the recommendation of the MGH Committee on Racial and Ethnic Disparities and staff of The Disparities Solutions Center, amended the Quality Policy on Data Management to include the following statement:

Racial and ethnic disparities:  In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.

This change will enable additional measures of disparities in quality of care within the MGH to be evaluated.

Quality Rounds. Quality and Safety Rounds were started at the MGH in 2002 with the goal of identifying key issues that could jeopardize patient safety or lead to medical errors. To achieve this goal, a doctor-nurse team routinely visits an inpatient floor and meets with multi-disciplinary members of the care team.  In 2003, a specific question focused on disparities was incorporated into the Quality and Safety Rounds. To date, the issue of language barriers has been identified with greatest frequency, but other issues raised in response to this question also include issues of understanding and acceptance of varying cultural traditions (particularly around gender issues, religion, and visiting policies and issues of access, particularly in the ambulatory settings). The process alone has raised awareness and sensitivity on the part of the staff.

Interventions.
Disparities identified as a result of the Disparities Dashboard are now being addressed through several culturally competent interventions.  Diabetes and colorectal cancer programs are in place at the MGH Chelsea Health Center (read more about these programs in the Chelsea section of this report). The Disparities Solutions Center is working with MGH Psychiatry on a pilot project to provide culturally competent psychiatric care and consultation for patients with multiple chronic illnesses as part of the MGH CMS demonstration quality improvement project.

Patient Experience and Access Subcommittee

Charge: Assess the experience of care at the MGH for patients of color, develop and implement action plan to address disparities.

Projects and accomplishments

Patient Survey.  A 400 patient telephone survey of minority patients (including 136 cross-sectional) was conducted in two languages (English and Spanish) to determine minority patients’ experiences of care at MGH. While the perception of equal quality of care for minorities is better at MGH than in society in general, there is still a significant gap, and almost ten percent of minorities could cite a specific example of unfair treatment, which they believed was based on race or ethnicity. In addition, two key themes were found: 1) The treatment, satisfaction and training of front line staff has a large impact on patients perceptions and experiences of care and 2)  It is not just language that is important, but also the overall sensitivity and compassion demonstrated by providers matters as well. The survey was developed and analyzed by Karen Donelan, Sc.D., and Nakela Cook, M.D., M.P.H.

Multicultural Advisory Committee.  The Multicultural Advisory Committee (MAC) has met quarterly since its inception on October 25, 2004. The committee is comprised of leaders, patients and their families from various minority communities, and is charged with advising MGH on minority patients' experience of care and perception of the hospital in minority communities. As a result of MAC recommendations, the MGH recently began a lecture series targeted at improving the service of front-line staff. This committee is co-chaired by hospital president Peter Slavin and senior vice president Jeanette Ives Erickson and staffed by Joan Quinlan, MPA, and Nakela Cook, MD, MPH.

Education and Awareness Subcommittee

Charge: Develop plans to educate/raise awareness among the entire MGH community of disparities and the factors that contribute to disparities

Projects and accomplishments

Awareness. The Education and Awareness Subcommittee has created a comprehensive communication strategy that focuses on increasing internal awareness of the issue of racial and ethnic disparities and the work of the MGH Committee.  This includes 11 articles in the MGH Hotline (a weekly newsletter for staff, employees, volunteers, visitors and friends of MGH), one in The Fruit Street Physician (a newsletter for MGH physicians), and three posters that have been displayed throughout the campus. 

Continuing Education. Committee leadership or membership is responsible for at least 4 presentations at grand rounds and leadership meetings per year and a semi-annual Disparities Forum.  The upcoming Disparities Forum will be held on January 23rd in the O’Keefe
 
Orientation. In late 2006, slides about the activities of the Committee and The Disparities Solutions Center were integrated into presentations attended by all new MGH employees as a part of the mandatory employee orientation. Information about general health and health care disparities are also included in this orientation.

The Disparities Solution Center
Joseph L. Betancourt, MD, MPH, Director

MGH launched the Disparities Solutions Center (DSC) in 2005, under the direction of Dr. Joseph Betancourt. The DSC is dedicated to the development and implementation of strategies that advance policy and practice to eliminate racial and ethnic disparities in health care. The Disparities Solutions Center achieves this mission by:

• Serving as a change agent by developing new research and translating innovative research findings into policy and practice.
• Developing and evaluating customized policy and practice solutions for health care providers, insurers, educators, community organizations and other stakeholders.
• Providing education and leadership training to expand the community of skilled individuals dedicated to eliminating health care disparities.

The Disparities Solutions Center is the first center of its kind in the United States.  While other disparities centers exist, The Disparities Solutions Center is the first to be based in a hospital, with a focus on moving the issue of disparities in health care beyond research and into the arenas of policy and practice.  The Center will serve as a national, regional, and local resource for hospitals, physician practices, community health centers, medical schools, other health professions schools, health plans and insurers, consumer organizations, and state and local governments.

The Disparities Solutions Center has received an initial funding commitment of $3 million from MGH and Partners HealthCare, as well as $1 million from the Robert Wood Johnson Foundation. Housed within the MGH/Partners Institute for Health Policy, the Center is affiliated with Harvard Medical School’s Department of Medicine and Health Care Policy and the MGH Division of General Medicine.

Now in its second year, the Disparities Solutions Center has many significant accomplishments to report:

• Continuing to build a diverse, talented team of faculty and staff
• Beginning a DSC Associates Program, now with 18 area researchers and clinicians with a broad set of interests and experience all dedicated to addressing racial and ethnic disparities
• Providing leadership to MGH projects focused on identifying and addressing disparities, especially in diabetes, colorectal cancer screening, and mental health
• Conducting the first Disparities Leadership Program, targeting leaders from hospitals, health plans, and community health centers from around the country
• Developing partnerships to address disparities across the country, including in Puerto Rico and New Orleans
• Leading several web seminars on prominent, timely technical issues and research findings
• Welcoming the first Aetna/DSC HealthCare Disparities Fellow, as well as several medical students for summer research activities
• Publishing 16 articles and chapters in peer-reviewed publications
• Playing a role in the media, with quotes from the DSC staff in several newspapers, trade newsletters and television/radio programs
• Sponsoring several local health fairs and events to provide support for educational programs, community awareness activities and commending leadership for addressing disparities
• Participating in the Disparities Action Network, an organization convened by Health Care for All to address disparities issues throughout the state of Massachusetts
• Launching a new interactive web site at www.mghdisparitiessolutions.org
• Supplementing seed funding with an additional $865,476 for Year Two activities