MGH Chelsea HealthCare Center

Thomas C. Sterne, MD, Medical Director, MGH Chelsea
Jeannette McWilliams, Administrative Director, MGH Chelsea
Sarah Abernethy Oo, MSW, Director, Community Health Programs
Elisha “Skip” Atkins, MD, MS, Center for Community Health Improvement Liaison
Kathleen Healey, CPNP, MSN, Center for Community Health Improvement Liaison

Background: City of Chelsea and MGH Chelsea HealthCare Center

Located two miles north of Boston, Chelsea is a city of three square miles and just over 35,000 residents (U.S. Census, 2000). Chelsea has been a gateway for refugees and immigrants entering the U.S. since the Industrial Revolution. In the past decade, Chelsea has represented a place of hope to large numbers of refugees fleeing countries devastated by war and poverty, including Bosnia, Somalia, Afghanistan, Northern and Western Africa, and countries in Central America. Latinos comprise more than 48 percent of the population, and 75 percent of Chelsea students. (U.S. Census, 2000, MA Department of Education, 2005). Just over 58 percent of residents speak a language other than English, and nearly 44 percent of residents speak Spanish (U.S. Census, 2000).

Indicators of poverty and violence in Chelsea are numerous and severe. Poverty levels are more than twice the statewide average. More than 27 percent of Chelsea households survive on less than $15,000 annually, and 43 percent of residents live at or below 200 percent of poverty.  Nearly 30 percent of children under age 18 live below the poverty line compared to the 10.1 percent statewide (U.S. Census, 2000).

Chelsea has a disproportionate number of young people; just over 27 percent of residents are 18 years of age or younger, (U. S. Census, 2000). Yet Chelsea’s ability to keep children and families safe is strained by high levels of violence. Chelsea has the second highest rate of child abuse and neglect child reports in Massachusetts (DSS, 2000), and violence-related injuries are six times the statewide rate, (MA Department of Public Health, 2000).

Avon Breast Health Outreach Program
Atala Esquilin, Avon Breast Health Coordinator
Denise Sidorowicz, ANP, MGH Chelsea

The Avon Breast Health Outreach Program aims to improve follow-up for women at MGH Chelsea who have had an abnormal mammogram through the use of a health “navigator.  The program targets Latina women. The program is a collaboration between the Avon Comprehensive Breast Evaluation Center at MGH, the Center for Community Health Improvement and Partners Community Benefit. This multi-site initiative includes two other health center sites in Boston.

The Breast Health Coordinator serves as a patient navigator and liaison between patients and providers, following up when patients miss appointments, and accompanying them to appointments when needed to help navigate through the health care system. The coordinator also works with those patients who miss their screening mammogram more than three times. The coordinator makes referrals to other community resources, and provides emotional support to patients undergoing diagnostic work-up or breast cancer treatment, including home visits as indicated. Through a special arrangement with the Avon Breast Evaluation Center, MGH Chelsea patients receive all required care (e.g. ultrasound, mammography, pathology) in coordinated appointments within a week of an initial finding, and have access to a Spanish interpreter. The coordinator also conducts outreach to women at risk for breast cancer, and participates in community events to increase awareness about the program.

Program Data

• Since its inception in May 2001, the program has served 608 patients including 85 patients with breast cancer (67 diagnosed while in the program and 18 breast cancer survivors).
• Since the program began, 62 percent of the patients served have been Latinas.

Bridging the Gap - The Refugee Family Service Project
Adnan Zubcevic, Refugee Program Manager
Tamara Leaf, PsyD, MGH Chelsea

Bridging the Gap is a partnership with Harvard and Tufts Medical Schools, which each identify volunteer medical students who are paired with immigrant/refugee families. Students support families in recognizing and addressing simple health-related needs and act as advocates, educators, mentors and friends, while learning first-hand the cultural issues that pose challenges to the families’ ability to access health care. Events and workshops are offered regarding obstacles families may face, available resources, Medicaid issues, and the resettlement process. The Office of Refugees and Immigrants and employment specialists from Chelsea Refugee Services in Boston provide training and assistance to the program. Bridging the Gap seeks to improve the cultural competence of future physicians.

2007 Program Accomplishments

• TUFTS Medical School has added a faculty mentor to provide active support to students as well as to coordinate student activities with the mentor from Harvard Medical School.
• The program was presented to the Coalition of Mutual Assistance Associations in spring 2007.

Program Data

• During its seventh year, the program matched 19 medical students with immigrant and refugee families from Afghanistan, Bosnia, Morocco, Somalia, Sudan, Western and Central Africa as well as with immigrant families from Central American countries and two families from Brazil.
• The program has increased the number of families served by engaging seven students more than the previous year.

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)
Susie Severino, CHAMP Program Coordinator
Elisha Atkins, MD, MS, MGH Chelsea
Eduardo Budge, MD, MGH Chelsea

The goals of CHAMP are to improve the management of care for MGH Chelsea patients with asthma with the aim of reducing emergency room visits and hospitalizations. Once a pediatric or adult medicine provider identifies a patient with asthma, the program coordinator facilitates communication and follow-up between the provider and the patient. During the same provider visit, the coordinator reinforces the patient’s understanding by providing education about asthma including triggers, symptoms, medications, and by reviewing the patient’s individualized action plan.  Barriers to follow-through are identified and strategies developed. As needed, the coordinator conducts home visits to reinforce asthma teaching and to identify potential environmental hazards in the home. The coordinator also identifies food resources, housing, domestic violence intervention, and referral to other programs as needed. The coordinator maintains a close relationship with the Chelsea Public Schools and nurses to identify students with asthma who are in need of services.

2007 Program Accomplishments

• The CHAMP coordinator participated in trainings including: Pediatric Asthma Update Conference, Asthma Delivery and Devices. Asthma Educators Institute at Partners Asthma Center. CHAMP Program Coordinator participated in a one day teaching session at the MGH Asthma center in Boston.
• CHAMP participated in Asthma awareness month (May). 
• CHAMP organized training sessions at MGH Chelsea for providers of Adolescent and Pediatric Medicine and the nurses group in Medical Walk In. 

Program Data

• Since its inception in 1997, CHAMP has seen over 800 patients through home and office visits.
• Annually, the program identifies over 70 new asthmatic patients.
• Program referrals come from Medical Walk In (74 percent), adult and pediatric providers (16 percent), and Neighborhood Health Plan high-risk patient registry (10 percent). 
• CHAMP maintains a Pediatric and Adult Asthma Registry to facilitate follow-up on health care matters, for example assuring all patients with asthma have regular flu shots. The program currently has identified and enrolled 1,462 asthma patients; 767 of these are adults and 695 are children and adolescents.

Children's Witness to Violence
Katherine Griffiths, LICSW, MGH Chelsea

MGH Chelsea is the recipient of a generous, multi-year grant from the Massachusetts Department of Social Services (DSS) to work toward helping children affected by domestic violence.  The goal of the Children’s Witness to Violence Program is to reduce the impact of family violence on families with  children.  Children’s Witness to Violence serves children ages seven to seventeen  and their families who have witnessed and/or experienced violence in their homes or communities.  Children’s Witness to Violence clients may have previously received or are currently receiving services from PACT, HAVEN (described below), Pediatrics and other MGH Chelsea departments, or may be referred from community organizations.

The complex nature of situations in which children witness or directly experience physical and/or emotional abuse requires ongoing and effective communication among a number of players.  These include DSS, and Harbor COV, the Chelsea domestic violence program, attorneys, guardians ad litem, the MGH Child Protection Team, and other community agencies. 

Children’s Witness to Violence services are uniquely designed to respond to the particular needs of young children, through mental health assessments, clinical follow-up, case management, and treatment.   Therapeutic groups for mothers and their children conducted simultaneously have been a particularly effective intervention.  One of the groups is for mothers and children  ages seven to eleven affected by domestic violence, using a curriculum developed by MGH clinicians is now used statewide. Groups are also run for mothers and their preschoolers ages 4 to 6, using a curriculum designed by MGH clinicians and a group from The Cambridge Guidance Center.  Lastly, mothers and their adolescents participate in separate groups , then meet together for dinner, both using the ARC (attachment, regulation and competency) curriculum designed by the Trauma Center in Brookline.

2007 Program Accomplishments
Groups for children who have been exposed to violence ages four to fourteen (including younger siblings of the referred child) have been fully implemented and have served approximately two dozen families.  The Children’s Witness to Violence Program has served almost every family that has been referred. 

Program Data

• In 2007, Children’s Witness to Violence committed to serve at least 22 children and their families in total for the year.  Most of these families continue in treatment for a minimum of two months.
• As a part of the Massachusetts Department of Social Services’ grant network, the Children’s Witness to Violence Program meets at least quarterly with domestic violence agencies statewide regarding collaboration. 

Chelsea Diabetes Management Program
Eddie Horta, M.A., MHC, Diabetes Coach

The Diabetes Management Program, launched in spring 2006, seeks to improve the care of all diabetics at MGH Chelsea and to reduce disparities in care between white and Hispanic patients.  This initiative was launched in collaboration with an initiative sponsored by the Mass. General Physicians Organization and the Disparities Solutions Center.

There are well documented disparities in diabetes care nationally. African Americans are 38 percent and Latinos 33 percent less likely than Whites to receive standard care for diabetes.  At MGH Chelsea, approximately one third of Latino diabetics did not have routine tests within the preceding nine months, and when they had the tests, nearly twice as many Spanish-speaking Latinos (41 percent) showed poor diabetes control compared to English-speaking Whites (23 percent).

The pilot program provides: individual coaching using a culturally competent, multilingual diabetes coach to assess specific factors that may lead to non-adherence to medication regimens, diet, and exercise plans; tailored education and interventions designed to address these issues; telephone outreach to patients to increase diabetes-screening frequency; and group education in English and Spanish through which patients share experiences and tips on diabetes self-management.

An evaluation of the program seeks to measure improvements in patients self-management; learn whether the program improves diabetes management for Spanish-speaking patients more, less or the same as for English-speaking patients; and determine barriers that patients have in taking care of their diabetes, such as lack of understanding of the disease, lack of family support, financial barriers, and perceived barriers to care due to immigration status.

Program Data

• The Diabetes Coach has worked with over 320 diabetics providing over 1400 individual and phone coaching sessions.
• The program implemented diabetes bilingual self-management education classes for over 100 patients.
• Preliminary research data shows significant improvements in diabetes management for patients in the program.  From a sample of 133 randomly polled patients,
• Latinos (100 patients) had a 13 percent  reduction in a key measure of diabetes control
• Whites (21 patients) had a 12 percent  reduction
• Patients of other races (12 patients from Brazil, Cape Verde, Morocco, Somalia, etc) had a 21 percent reduction

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

The Center for Community Health Improvement 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. 

Chelsea High School Student Health Center
Jordan Hampton, RN MSN CPNP, Nurse Practitioner
Sheila Desmond, MD, Medical Director

MGH Chelsea has operated the Student Health Center (SHC) at Chelsea High School since 1990.  The goal of the SHC is to increase the number of high school students receiving primary and specialty health care.

The SHC provides confidential, comprehensive health care to teens who might otherwise not receive it, including physical exams, reproductive health care, mental health counseling, nutrition, preventive health education, and treatment for acute, episodic and chronic illnesses. The SHC staff collaborates with health center primary care providers and specialists to ensure continuity of care and appropriate follow up. The SHC also provides classroom presentations on reproductive health, a support group for pregnant and parenting students through the Circle of Care program, and sponsorship of the Stay in Shape program, designed to address health, nutrition, and physical activity among female students.   

2007 Program Accomplishments

• The Student Health Center completed its third year of the WK Kellogg Foundation School Based Health Care Policy Initiative.
• SHARE students (Student Health, Advocacy, Research and Education) sponsored Domestic Violence Awareness Day, the Great American Smoke-out, World AIDS Day, and a nutrition policy campaign.
• SHARE students attended the second annual School-Based Health Care Advocacy Day at the State House in February 2007, which featured a Chelsea High alumna as keynote speaker and Jordan Hampton as emcee.   Students met with legislators and Governor Patrick to discuss the importance of school-based health care.
• SHARE students collected signatures on Declarations of Support for school-based health care and also signatures on postcards in support of the School-Based Health Clinic Establishment Act which were presented to the offices of Senators Kennedy and Kerry in Washington DC June 2007.  
• Senator-elect Anthony Galluccio visited the SHC in September 2007. 

Program Data

• 411 students were patients at the SHC during the 2006-2007 school year.
• There were a total of 1242 primary care visits, and 473 mental health visits.

Colorectal Cancer Screening Program
Gloria B. Gamba, Colon Cancer Screening Coordinator
Sanja Percac-Lima, MD, PhD, MGH Chelsea

The Colorectal Cancer Screening Program aims to improve colorectal cancer screening (CRCS) for all eligible patients at MGH Chelsea, and to decrease disparities in CRCS rates that exist between Latino and White patients, as well as in low income and non-English speaking populations in Chelsea.

The Colorectal Cancer Screening Coordinator works closely with the Gastroenterology (GI) Department at MGH Boston and with Adult Medicine providers to facilitate the referral and communication between the MGH specialty department and the patients. The coordinator provides education on colon cancer screening options and explores and works on addressing the individual patient’s barriers to colon cancer screening.  The coordinator provides education on colonoscopy procedures and also provides emotional support. The coordinator serves as a patient navigator to schedule and remind patients about appointments, help them access insurance, explain instructions for their test preparation and translate written material.  The coordinator also accompanies patients to their GI appointments and interprets during the appointment if needed.  Screening results and patient contacts are documented in a program data base.   The program also seeks the help of MGH Chelsea interpreters/outreach workers to reach other non-English speaking patients, primarily Arabic, Bosnian Portuguese, and Somali patients.

The program was launched with support from an MGH Clinical Innovation Award to Sanja Percac-Lima, MD, PhD.

Program Data

• Since the program began in January 2007, it has been offered to 409 patients between the ages of 52-79 years old.
• The navigator has contacted 310 patients.
• 92 patients had colonoscopies.
• 56 patients completed and returned Fecal Occult Blood Test cards (FOBT).
• To evaluate efficiency of the program, a randomized controlled trial (RCT) was carried out from January to October of 2007:

• All (1223) patients 52-79 old at Chelsea HC overdue for CRC screening were randomized to intervention (n=409) or usual care control (n=814) group.
• Over the nine-month period, intervention patients were more likely to undergo CRC screening than control patients (27 percent versus 12 percent). Most of the difference among intervention and control patients was attributable to significantly higher colonoscopy rates (21 percent versus 10 percent).
• The higher screening rate resulted in the identification of 10.5 polyps and 0.24 cancers per 100 patients in intervention group vs. 6.8 polyps and 0.12 cancers per 100 patients in the control group.

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.

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HAVEN at MGH Chelsea
Marisol Coreas, HAVEN Advocate
Niza Troncoso, HAVEN Advocate

HAVEN at MGH Chelsea, part of the hospital-wide HAVEN program, works as part of the broader movement to end intimate partner abuse by improving and enhancing our health care response to 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. HAVEN participates in the Chelsea community-wide Domestic Violence Task Force, multidisciplinary assessment team meetings at DSS, and in a community faith-based initiative. HAVEN is an active member of MGH Chelsea’s Safe Start Program and the Family Violence Team. 

Two bicultural HAVEN advocates train healthcare providers to ask patients about partner abuse sensitively and effectively. If a patient discloses abuse, the provider offers the services of a HAVEN Advocate, who works to empower survivors to better understand the dynamics and impact of abuse, increase their safety, review options, and heal from the abuse in their and their children’s lives. 

2007 Program Accomplishments

• HAVEN offered De Mujer a Mujer, a ten-week curriculum-based support group for Latinas confronting violence, including sessions about traditional roles within a family, STDs, and domestic violence.
• A HAVEN at MGH Chelsea advocate traveled to Peru to train providers in rural and urban health care centers in the use of the De Mujer a Mujer curriculum.
• A HAVEN advocate co-facilitated a mother-child group with a clinician from the Safe Start Initiative

Program Data

• Since its inception in 1997, HAVEN at MGH Chelsea has provided services to more than 672 clients, 72 percent of whom are Latina and 92 percent of whom have children. 
• 48 percent of their abusers are active users of alcohol or drugs, 31 percent have threatened to kill the patient, 15 percent have threatened the patient with weapons and 9 percent have actually harmed the patient with weapons. 
• Over 40 patients have participated in De Mujer a Mujer since the group began.

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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.

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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 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.

Police Action Counseling Team - PACT

Georgia Green, LICSW, MGH Chelsea 
Thomas Dunn, Lieutenant, Chelsea Police Department

The goal of the Police Action Counseling Team (PACT), founded in 1998, is to reduce the immediate impact of trauma on children who witness violence in Chelsea.  Ultimately, PACT seeks to reduce the effects of trauma on a child's ongoing development, and to interrupt the cycle of family violence.  PACT is a partnership between the MGH Chelsea, the Chelsea Police Department, the MGH Child Protection Consultation Counseling Team, and the MA Department of Social Services (DSS).  PACT clinical social workers are available by beeper 24 hours a day, seven days a week for on-the-scene response to 911 calls when children are present.  Once police officers establish physical safety, social workers provide on-site developmentally appropriate interventions by helping children to express their fears, sadness, anxiety, hope and other feelings, providing information and answering questions so that children can feel more in control of their circumstances, and helping children identify and undertake immediate next steps, such as gathering belongings if they need to relocate, or arranging for transportation to school the next day.

PACT social workers also help parents and other family members understand the short and long-term effects of violence on children, provide them with language-appropriate resource materials, and offer assistance in managing the symptomatic aftermath of such incidents. PACT connects families with services, such as medical and mental health care, domestic violence shelters, court advocates, and facilitates connections with school personnel, clergy, and whomever the family identifies as a support network.  Weekly team meetings at the Chelsea Police station with social workers, police officers, and DSS assure all are communicating effectively on behalf of the family. 

2007 Program Accomplishments

• PACT provided training to MGH psychology and social work interns, and psychiatry residents as part of their community medicine rotations.  Additionally, interns and residents can opt to ride with police to gain exposure and insight into the crises that families face that can result in the need for medical and mental health interventions.
• New police officers were oriented to PACT as part of their general orientation when joining the Chelsea PD.
• PACT was chosen by the American Hospital Association for its January, 2007 publication, Community Connections, Ideas & Innovations for Hospital Leaders.
• PACT began a new process of rotating officers through weekly PACT meetings, to involve officers in the discussion and follow up on cases they have paged on.  This process also provides ongoing officer training and assists program development.
• PACT personnel participated in a strategic planning meeting at the Suffolk County Children’s Advocacy Center. This agency as part of the District Attorney’s Office handles cases of physical and sexual violence against children.
• PACT clinicians are now involved with Chelsea police detectives in child sexual assault cases.  Clinicians are now paged by a detective, and respond immediately to a child victim’s caretakers.  Interventions are designed to provide immediate response to the crisis, familiarize caretakers with the legal, medical and mental health processes ahead, and most importantly to help caretakers manage their own and their children’s immediate emotional and safety needs.  This important initial contact greatly increases clinical follow up care for the child and family.
• PACT has initiated an interagency dialogue around improving access to services for children who set fires. 
• PACT presented the program to members of the Zonta Club of Chelsea.
• In October, The Chelsea Domestic Violence Task Force awarded Georgia Green the Public Service Award at its annual community breakfast in appreciation for her leadership working for community solutions to end domestic violence.
  
  Program Data

• PACT has provided services to 712 families including 1435 children seen since 1998.
• In 2007, PACT was paged 137 times with an additional 51 cases referred and 23 cases received from other sources (log book, being at CPD, etc.) totaling 211 cases for the year. Out of these 211 cases, 275 children were involved.
• Over 50 percent of cases were seen in person or contacted by phone. PACT saw 50 families, contacted 67 families by phone, and left messages or sent pamphlets to the remaining 118 families.

In 2007, of the 50 families directly served by PACT:

• 104 children were involved.
• Seventy-five of those children witnessed domestic violence
• Substance abuse was involved in eleven cases
• 14 adults and three children were physically injured and four adults and two children required medical assistance
• Eleven 51-A’s were filed and 18 restraining orders were issued as a result of meeting with PACT clinicians 

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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 Community Benefits 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. 

Safe Start Promising Approaches
Pam Miller, Ed.D, MSW, MGH Chelsea

The goal of Safe Start Promising Approaches (Safe Start) is to reduce the harmful effects on children of exposure to violence, as well as to enhance the delivery of services to children and families through effective community collaborations.  MGH Chelsea is one of 15 Safe Start sites nationally funded by the U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
 
Safe Start builds on the long-standing community partnerships that exist with the Chelsea Police Department, DSS, and HarborCOV.  These collaborations provide consistent opportunities for staff across agencies to share expertise and knowledge about the impact of children’s exposure to violence.  Reciprocal education and training sessions are offered and staff collaborate to expand, enhance, and develop policies and procedures to improve systems and facilitate referrals and communication with community partners.

Through a multi-disciplinary team of MGH Chelsea providers, Safe Start coordinates the extensive support, services, and resources required by children who have been exposed to violence and their caregivers.  These include:

• Improved capacity to identify and refer children and families exposed to violence to services.
• Linkages to needed medical care and additional health care resources.
• Individual and family mental health treatment.
• Group sessions for parents and children, developed with particular emphasis on attachment and affect regulation.
• Home visits to assess physical safety, child supervision, and exposure to media that can contain violent content, such as TV, videogames, and music.
• Services as needed through HAVEN, PACT, and the Child Protection Consultation.

The MGH Chelsea Family Violence Team includes multi-disciplinary health center staff and community partners from Chelsea, including DSS, the police, and the Boys and Girls Club.  During monthly meetings, providers engage in planning for Safe Start families facing particularly complex challenges. The team also regularly brainstorms about improving family interventions and providing new systems for interagency communication. Community members are often invited to use meetings as a forum to address topics about violence exposure, and guest speakers are frequent participants.  This year, Safe Start trainings for MGH Chelsea staff and community partners have included clinical training about attachment and self-regulation for older children and their caregivers, the science of early child development, and understanding sensory-motor integration issues.

2007 Data and Program Accomplishments

Since its launch in June, 2006 Safe Start has received 147 referrals for children ranging in age from infancy to late adolescence.

• Safe Start recruitment events have been attended by over 50 different families. 
• Fourteen home visits have been completed.
• A comprehensive evaluation of the 15 Safe Start sites is on-going to assess the effectiveness of intervention approaches and develop methods by which to better understand the consequences of community collaboration.  The evaluation in Chelsea has thus far enrolled 26 families and followed them for up to a year. Comparison site families from Revere have also been enrolled. 
• Over a dozen groups for children and parents have served 42 different children.
• The Harbor Office of the Department of Social Services has collaborated on a plan to use Safe Start funding for programs on issues concerning racial disparities in treatment.
• The Chelsea Police Department has begun to use Safe Start funding to place more officers with families exposed to violence in order to assist both children and adults with criminal prosecution issues, and to purchase needed supplies to use with siblings and children when officers are assisting families.

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.

Visiting Moms Program
Amal Ali, Visiting Mom
Fadumo Hirsi, Visiting Mom
Rosa Mojica, Visiting Mom
Tania Soares, Visiting Mom

The Visiting Moms Program provides home visitors to high-risk new mothers who receive care at MGH Chelsea, with the goals of helping families achieve stability in order to enable healthy long-term outcomes for the child, the mother, and the family, and to reduce abuse and neglect.

Pregnant and parenting women are referred to the Visiting Moms Program from the health center’s Prenatal, Pediatrics, or Mental Health Departments, as well as from the inpatient MGH Obstetrics and Pediatric Units. Bicultural home visitors support the new mothers, ages 21 and above, with adjusting to and caring for their children. Visiting Moms offer emotional support, concrete assistance, advocacy, referral to resources, and information about child development and the care of infants and young children. The Visiting Moms serve as role models, demonstrating ways to adapt to a new country and culture including numerous stressors such as unemployment, lack of finances, language barriers, immigration problems, difficulty accessing benefits, and emotional and physical abuse. The mothers’ traditional parenting techniques may be difficult to maintain.  Reducing isolation of the mothers is of central importance to the work. 

Collectively the mothers speak more than ten languages, including Spanish (52 percent), Somali, Arabic, Portuguese, Swahili, Ugandan, Dari, Haitian Creole, French and Cantonese.  The Visiting Moms speak five of these languages, thereby increasing their ability to encourage the mothers to use available resources, some of which the Visiting Moms themselves might have used.  The Visiting Moms are able to maintain these supportive relationships for up to three years. Most of the families have used these services for six to twelve months, by which time many of the mothers have returned to work.

2007 Program Accomplishments

A poster on the Visiting Moms Program was presented at the 2007 Community-Campus Partnerships for Health conference in Toronto Canada.

Program Data

Since the Visiting Moms Program began in 2002, 148 cases have been opened, with 53 mothers currently enrolled in services.  More than half of the women are new mothers; many of the children of the other women remain in their home countries with relatives.

Over the past year, the Visiting Moms have had over 1,700 encounters with 68 moms, babies, and families, for an average of 25 encounters per client.   33 percent of these encounters involved a home visit, while 36 percent involved an office visit.  26 percent of these encounters involved translating documents or assistant with paperwork.  11 percent of these encounters involved accompanying a patient to an appointment and seven percent involved helping a patient make an appointment.

Women in Need
Leslie Aldrich, MPH
Edward Conley, Sergeant Detective

The Chelsea Police Department (CPD) received funding from the Massachusetts Executive Office for Public Safety to conduct a needs assessment of commercial sex workers (CSW) in Chelsea. The RET is collaborating with the CPD to conduct interviews and surveys with up to 40 women.   To date, 11 interviews have been conducted with preliminary results indicating food and housing are the most immediate needs. 

Although the majority of the sample had current housing, almost all of the women interviewed (90 percent) report being homeless at some point in their lives.  In addition, the majority (60percent) worry about where to get their next meal.  All of the women report having health insurance with the majority seeking out medical care when they feel it is necessary. Violence is also a real concern with 100 percent of the sample interviewed exposed to some sort of personal abuse at one time in their lives. The majority of CSW's report being abused by clients and over half report some type of childhood verbal, physical or sexual abuse from an adult or parent. Seventy percent report being physically and sexually abused by someone they dated.

Using drugs and alcohol before the age of 13 is common for this population with a high percentage of women reporting having used, and in many cases continuing to use, both cocaine and heroin. Unfortunately exchanging sex for money has only exacerbated these women’s addiction issues with 63 percent reporting that their drug use has increased since entering into prostitution. Although 80 percent of women rate their health as very good or good, 50 percent report currently feeling depressed enough that everything was an effort all or most of the time.  In addition, 88 percent of these women report feeling sad or hopeless every day for two weeks or more. When discussing potential services that may benefit their lives, all women (11) expressed an interest in receiving an education and developing useful job skills. In addition, all women thought services around food, clothing and childcare would be helpful followed by mental health services (91 percent), job training (91 percent), basic medical care (82 percent), and safe and accessible drug treatment (64 percent). Six out of eight women expressed the need for affordable housing.
 
Although initial data from this assessment reveals the need for direct services for these women, more data must be obtained. Once data collection is complete, the Chelsea Police Department and researchers at the MGH plan to collaborate with local community agencies and institutions in order to interpret the findings and assess resources for potential treatment and services and to develop a research-based harm reduction and safe intervention model for sex workers in Chelsea.