1. Expanding Health Center Enabling Services: Health Leads BPHC Grantee Enrichment Call April 12, 2012

2. 2 1960s photograph of Delta Health Center in Mississippi Delta

3. 3 1995 Photograph of exterior of Boston Medical Center

4. Robert Wood Johnson Promise Story 4

5. 5 Health Leads’ Model

6. Trends in Healthcare 6 1.Risk Sharing 2.Patient-Centered Medical Home 3.Primary Care Workforce Shortage

7. Institute for Healthcare Improvement Triple Aim Healthcare Workforce and Leadership Quality= Improve the health of the population Patient Experience= Enhance the patient experience of care Cost of Care= Reduce, or at least control, the per capita cost of care 7 QualityPatient ExperienceCost 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 & Leadership

8. 8 Patient Centered Medical Home Standards

9. Partnerships with Federally Qualified Health Centers 9 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

10. 10 Grantees: Myechia Minter-Jordan Rachel Bowers

11. 11 Health Leads Station

12. 12 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

13. 13 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

14. 14 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

15. 15 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

16. 16 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

17. 17 Grantees: Myechia Minter-Jordan Rachel Bowers

18. 18 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

19. 19 Health and Community Services – Health Leads Community Care (HIV/AIDS) Services Child & Family Development Services Behavioral Health Services Adult Education Programs Services & Programs

20. 20 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

21. 21 Grantees: Myechia Minter-Jordan Rachel Bowers