Expanding Health Center Enabling Services:

Health Leads

BPHC Grantee Enrichment CallApril 12, 2012

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1960s photograph of Delta Health Center in Mississippi Delta

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1995 Photograph of exterior of Boston Medical Center

Robert Wood Johnson Promise Story

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Health Leads’ Model

Trends in Healthcare

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1. Risk Sharing

2. Patient-Centered Medical Home

3. Primary Care Workforce Shortage

Institute for Healthcare Improvement Triple Aim

Healthcare Workforce and LeadershipQuality= Improve the health of the population

Patient Experience= Enhance the patient experience of careCost of Care= Reduce, or at least control, the per capita cost of care

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Quality Patient

Experience Cost of Care

Improve the health of the population

Enhance the patient experience of care

Reduce, or at least control, the per

capita cost of care

Healthcare Workforce & LeadershipHealthcare Workforce & Leadership

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Patient Centered Medical Home Standards

Partnerships with Federally Qualified Health Centers

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• Chicago Family Health Center– Warren Brodine, Chief Executive Officer

• Dimock Health Center, Roxbury, MA

– Dr. Myechia Minter-Jordan, Chief Medical Officer

– Rachel Bowers, Social Worker- Clinical Pediatrics

• Baltimore Medical Systems at St. Agnes

• Codman Square Health Center, Dorchester, MA

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Grantees:Myechia Minter-Jordan Rachel Bowers

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Health Leads Station

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• Brought to us by community organizations– Had seen positive impact of Health Leads at University of Chicago– Desire to expand Health Leads into a predominately Latino health

center– Funded first year

• CFHC agreed to pilot the program– Required that volunteers accept referrals from all 5 CFHC sites

• Tested Health Leads’ first “remote” referral process

Health Leads at Chicago Family

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• Connections to social services

• Volunteers work closely with Social Work Program- Provide support to CFHC's 1.0 FTE Social Worker

• Available resource to medical, dental and behavioral health providers when patients identify social determinants of health issues

How CFHC views Health Leads

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• Health Leads' volunteers handle two types of cases for the most part– Rapid Resources referrals – pre-packaged client support referrals

that save time in the exam room and of the CFHC Social Worker– Needs that require detailed intake and follow up

• Multiple client contacts to connect to housing, employment, insurance coverage

• After detailed review of year 1 outcomes, CFHC agreed to share costs of Health Leads

Health Leads as a Core Program at CFHC

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• Year 1 Totals– 48 Volunteers– 532 Clients Served

• 912 presenting resource needs

• Year 2 to date (Program Year start September 1)– 50 Volunteers– 314 Clients Served

• 647 Presenting Needs

• Top Three Presenting Needs in FY11– Employment (26%)– Income/Benefits (25%)– Housing (19%)

Health Leads Impact

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• Providers are willing to ask patients questions about their social determinants of health issues– Before Health Leads, providers were “afraid” to ask questions that might uncover issues

of housing, food insecurity, etc., because they had very few resources to help them

• Provider engagement is the key– The program works best when providers make the referral to Health Leads’ volunteers

• Can’t help everybody– Needs in the community are so deep, an army of volunteers can only scratch the surface

What We’ve Learned

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Grantees:Myechia Minter-Jordan Rachel Bowers

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Our Mission

At Dimock, we believe every life is precious. We commit to enhance the quality of life of each individual we serve, of the people we employ, and the communities in which we live by providing accessible, comprehensive, innovative, culturally competent health and human services.

Our Vision

Our Vision is a healthy community where we make a difference in every life.

Our Leadership

Ruth Ellen Fitch, President & CEO

Mission and Vision

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• Health and Community Services– Health Leads

• Community Care (HIV/AIDS) Services

• Child & Family Development Services

• Behavioral Health Services

• Adult Education Programs

Services & Programs

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2010-11 numbers:

• 13,433 patients• Over 40,000 visits/yr• 55% Black, 45% Hispanic• 70% Medicaid

Clinics/Services

• Adult Medicine• OBGYN• Optometry• Dental• HIV services• 340B Pharmacy• Pediatrics - 8700 visits in

the last year

Our Health Center at a Glance

Our Health Center at a Glance

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Grantees:Myechia Minter-Jordan Rachel Bowers