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May 18, 2016

Elders Living at Home Improves Health with Housing

What is a house? Is it a space to keep your things, a place you always feel comfortable, or something else? We often don’t think about housing as a part of a healthy life, but housing and health are strongly linked. Housing insecurity can not only make existing health problems worse, but can even cause new health problems. Boston Medical Center’s Elders Living at Home program aims to increase health by helping housing insecure or homeless people find or stay in housing.

“The health consequences of homelessness are serious, especially for older people, who may already have chronic health issues,” says Eileen O’Brien, program director of Elders Living at Home. “Part of real preventive medicine, therefore, is keeping people in houses. More and more, we’ve been providing services to prevent housing loss, as the best possible outcome is for a person to never be homeless.”

Elders Living at Home provides case management for people 55 or older who are homeless or at risk of becoming homeless. The program has between 100 and 120 clients at any given time, and receives five or six new cases a day, though not all become clients. Services are tailored to client needs, such as helping homeless clients transition to housing or preventing housing loss if clients are in danger of losing their home. The program’s unique approach is “extreme case management” – a hands-on approach that works to address both housing issues and the underlying issues that are causing housing instability or homelessness. When underlying issues are identified, Elders Living at Home works to help clients solve them, partnering with other providers, outside organizations such as Medical-Legal Partnership Boston, or other social services.

The Elders Living at Home program began in 1986 as part of a national effort to determine what different communities need to help people stay in those communities. Boston was one of 20 sites, and at the time, was in the midst of a housing crisis. Elders Living at Home, at the time part of University Hospital’s Home Medical Services, received a three-year grant to help find housing for residents and keep them in Boston. The program has grown from there, and continues to be affiliated with BMC’s Geriatrics Department.

In the years since its founding, Elders Living at Home has run a number of groundbreaking transition programs, such as working with Boston Housing Authority to temporarily house homeless clients in empty BHA apartments. Through this program, now discontinued due to lack of funding, Elders Living at Home was able to help people who had been homeless for 20 years or more.

“We’ve been fortunate in our ability to run innovative programs. We were one of the first Boston organizations to recognize the specific needs of homeless elders, who, along with children, are a particularly vulnerable population,” says O’Brien. “We were providing housing first – where people are placed in housing and then provided with services – before it was called that, and now it is a national model for helping to end homelessness.”

Elders Living at Home has three full-time case managers and a part-time nurse, in addition to a program director and a program manager. Referrals to the program come from within BMC, other hospitals, community and government agencies, and self-referrals from patients. When patients are referred to Elders Living at Home, they can have varying degrees of acute needs; the only real requirements are that they are 55 or older and have a housing need. The program mostly serves individuals or pairs.

Currently, the program only serves Boston, but hopes to expand to the Greater Boston Area in the upcoming year. O’Brien says that Elders Living at Home is looking at potential partners agencies in Malden, Quincy, and Brockton, so that the group can provide services to even more elders in need of housing assistance.

To learn more about Elders Living at Home, visit the program website.

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A Medical Home for Children with Sickle Cell Disease

Childhood and teenage years can be hard for anyone, but they can be particularly hard for children with sickle cell disease (SCD), a chronic, genetic blood disorder. The painful attacks that are the hallmark of the disease can be debilitating, but the pediatric SCD team at BMC is working hard to help ensure that these patients get proper and holistic care, so that they can live their adolescence as normally as possible.

In sickle cell disease, red blood cells can form rigid sickle shapes, at times cutting off blood flow to various parts of the body and causing significant pain. Long-term consequences of SCD include stroke and organ damage/failure, and life expectancy in the United States for people with SCD is approximately 50 years.

The BMC team, which currently serves 200 patients ranging in age from newborn to 22 years, takes a unique population-level care view. Rather than focusing on acute care once a vaso-occlusive episode is already underway, the team strives to prevent such crises in the first place by seeing patients frequently to provide education and tips on prevention. They also work to identify and overcome barriers to care, such as transportation to clinic visits.

The pediatric SCD program functions as a medical home for patients. The SCD team, including two doctors and a part-time nurse, sees patients for urgent care issues during regular clinic hours, allowing patients to avoid the ED when possible. A dedicated social worker helps address non-medical issues, such as making sure each child has a specialized education plan that allows them to avoid some of the environmental factors that can trigger attacks, or helping parents with other issues, such as the possibility of utilities being turned off. The team works closely with a psychologist to help patients cope with having a chronic disease and has a patient navigator to help guide patients through their care.

Medication also helps BMC successfully care for patients with SCD. Hydroxyurea has been shown to decrease the number and severity of SCD attacks, but in many places, less than half of eligible patients are using the medication. At BMC, between 80 and 90 percent of eligible patients are using it at any given time.

The pediatric SCD team has worked to make access to hydroxyurea easier for BMC patients. Liquid hyroxyurea, which is easier than pills for pediatric patients to take, has to be specially made by compounding pharmacies, which often charge high fees and are inconveniently located. The team formed a partnership with BMC’s inpatient adult chemotherapy pharmacy, which has the ability to compound hydroxyurea. As a result of that partnership, SCD patients can pick up hydroxyurea at the Shapiro pharmacy, reducing both fees and travel.

“Medication adherence is a huge problem in sickle cell disease, particularly in adolescents with the disease,” says Amy Sobota, MD, MPH, a pediatric hematologist who works with patients with SCD. “Any steps we can take to reduce barriers to medication are very important in managing SCD. Our goal is to get treatment to patients, and to do that, we need to be willing to figure out and address the barriers to optimum preventive care.”

The pediatrics SCD team at BMC has built a patient registry that tracks patients, treatments, and other health information. The registry is currently being rebuilt in Epic and the new version will allow the team to run reports to help identify and address potential issues – for example, identifying and following up with patients that didn’t receive a flu shot. The registry will help BMC and patients meet goals for SCD care, as well as general health metrics.

On these general health metrics, BMC outperforms other care providers for pediatric patients with SCD. Eighty percent of BMC’s patients two years and older have been vaccinated against meningitis and between 85 and 90 percent have been vaccinated against pneumonia. In addition, more than 85 percent of patients received flu vaccinations last year, compared with 59 percent of all children in the United States, according to the Centers for Disease Control. While there is limited data on vaccination rates for children with SCD, select studies show that BMC’s vaccination rates are among the highest.

“There’s not a lot of fancy technology to help patients with SCD, but doing things meticulously is what keeps kids out of the hospital,” says Sobota. “Our approach provides a model for how to work in the new ACO model that MassHealth is moving towards. We are a small team taking care of and coordinating care for a small group of complex patients, and we have been very successful in doing so.”

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A Tool to Reduce Readmissions at BMC

What happens to our patients when they leave the hospital? Sometimes we see them at clinics, sometimes we never see them again, but too many end up back in the hospital within 30 days. Hospitals are traditionally set up to care for patients during an acute episode, but preventing readmissions can be an important part of care, both for positive patient outcomes and for the hospital’s performance on quality metrics tied to funding. As a result, a team at BMC is working to create a hospital-wide strategy for preventing readmissions.

“In some ways it may seem counterintuitive to try to keep people out of the hospital,” says Carrie Solomon, Senior Manager of Strategy Implementation. “But we’re a whole system, not just the hospital, and we want to care for the whole patient, not just an acute care episode. Some people who come in are just sick, but many have other issues that drive health problems, and we can utilize primary care, specialty care, other hospital programs, and community resources to help keep people from needing acute care.”

BMC is working on a hospital-wide strategy to reduce unnecessary readmissions that seeks to address the complex clinical and psychosocial issues that many at-risk patients face, such as homelessness or substance use disorders. BMC’s readmissions rate has been trending down due to the work departments have been doing to prevent readmissions, and the hospital has made it a priority to continue this downward trend. Performance on readmissions is tied to $15 million in funding from the state and federal government, but reducing readmissions is also important to help BMC prepare for upcoming policy changes.

“While there are currently some penalties for readmission rates, we know health reform is coming,” says Alexandra Yurkovic, MD, Medical Director of Strategy Implementation. “The reality is that up until now, each readmission was more money for the hospital, but when there’s a Medicaid accountable care organization, things will be very different, and keeping people out of the hospital will be a priority. But what this really means is that financial incentives are catching up with what feels clinically right – to keep our patients as healthy as possible.”

Solomon and Yurkovic worked with BMC’s data analytics team to pinpoint the biggest drivers of readmission, based on a year’s worth of BMC patient data, and identified 14 key factors. Those factors are used to calculate a score – in real-time – for every patient admitted to an adult medical inpatient unit. The scores are displayed in eMERGE patient charts upon admission so that providers and ancillary services can identify patients at the highest risk of 30-day readmissions and focus targeted interventions and resources where they will make the biggest difference.

Patients are segmented into four groups, with a focus on the two most at-risk cohorts: super utilizers, who represent five percent of admissions and have a 63 percent chance of being readmitted, and high-risk patients, who represent 15 percent of admissions and have a 54 percent chance of being readmitted. Moderate risk patients, who represent 30 percent of admissions and have a 17 percent chance of being readmitted, will receive lower-touch interventions such as post-discharge phone calls.

Super utilizers and high risk patients receive high-touch interventions to help reduce readmission rates. An inpatient pharmacist meets with each patient to conduct a patient interview focusing specifically on medication history and medication reconciliation. A social worker also meets with each patient to perform a psychosocial evaluation to find out what non-medical issues could lead to a patient’s readmission. In addition, an order set will come up in eMERGE for physicians to follow and ensure that patients get any specialty care they need while admitted.

When super utilizers and high-risk patients are discharged from the hospital, they will leave with a follow-up appointment scheduled at a time that they have specifically said will be convenient for them. A pharmacist double checks each patient’s medications before they leave, and follows up with a phone call within two days to check in on the patient and make sure there are no medication issues. Additionally, all patients will receive improved discharge paperwork, which will have key information up front about red flags, who to call if there are issues, follow-up appointments, and medications.

The hospital is also working to ensure that patients continue to receive the services they may need post-discharge. This includes working with BMC primary and specialty care clinics and developing partnerships to leverage community resources such as Boston Healthcare for the Homeless to meet the complex psychosocial needs of patients and support improved transitions of care.

Super utilizers also receive additional attention. A super utilizer team, led by case manager Colby Bowden, RN, a pharmacy technician, and a social worker manage super utilizers during their admission and for 30 days post-hospitalization to support patients’ transitions out of the hospital. They meet patients at the bedside during their hospitalization, and then call each patient weekly to monitor clinical, medication, and psychosocial needs. If any issues arise, the team helps the patient get appropriate care, and serves a general liaison between the patient and needed services. If a patient in this program is not readmitted within 30 days, they “graduate” from the program and are reenrolled if they are admitted to the hospital at a later date.

In addition, the hospital is also targeting certain conditions that are associated with high readmission rates, such as sickle cell disease, substance use, or congestive heart failure. Patients with those conditions will also receive increased attention. Nurse practitioners will help manage patients with these clinical conditions across the care continuum, providing care during admission and seeing patients for follow up soon after discharge. This program is currently in place for patients with sickle cell disease and other programs will go live in the next few months.

“Preventing readmissions can be challenging because so many people touch patients before, during, and after their hospital stays,” says Yurkovic. “Everything we’re doing is a work in progress, but everyone involved is very excited by and engaged in this work. The hospital has a very collaborative environment, which makes a big difference for our work, and ultimately for our patients.”

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What do you do, Charles Green?

Name: Charles Green
Title: Associate Director of Food and Nutrition
Time at BMC: 20 years

What do you do here?
My typical day runs from 5 a.m. to 6 p.m. The first thing I do is get the first of many coffees I have throughout the day. I deal mostly with compliance, so then I go through each Food Service area and make sure they’re all compliant with safety policies and that they’re ready for cash handling. The rest of the day, I do run-of-the-mill managerial things – I train staff, deal with employee relations, and all those sorts of things. I also make sure we’re ready for any inspections or audits, like The Joint Commission or Department of Health.

Throughout the day I get to taste all the food before it gets served, which is a great part of food service. I want to make sure the chefs are complying with our recipes, but the love they put in the food in unbelievable. I call them artists of food. And as I go through all my other tasks, I like to say hello to as many people as possible around the hospital, with what I’ve been told is an infectious smile.

What brought you to BMC?
Opportunity brought me here. Before this, I was working as an ADT telemarketer and at StrideRite, but StrideRite was closing. I was getting bored and I knew that BMC was hiring for food and nutrition, which my first job was in – I worked for my father at Stage Deli.

I wanted to get back into food, so I applied and I started part-time passing trays in the dish room. I became full-time and worked up to supervisor, then to assistant manager, and up until now.

The new Yawkey cafeteria is opening soon. What can you tell us about it?
Everything will be showcase cooking. We’re going to have Sono, a Chef Jet, American grill – you name it, we’ve got it. And we’re hiring all chef-managers, not just managers, so if something happens, you’ll have a chef-manager that can hop right in and help.

I’m also really excited about the new gift shop in Menino. We’re going to have a full-blown Starbucks menu, where you can get lattes, and sandwiches. It’s going to be key, sitting right there in the main lobby.

What’s one thing about working in Food Services that people might not guess?
It might seem like it’s easy to just serve food, but it’s hard work. I call it “four pots of food” to put together – Patient Services, retail, catering, and the ordering/recipe compliance. As you serve the food, there are so many regulations we need to comply with and tasks that the average person doesn’t see. For example, once a week we do inventory, where we count each individual food item in the stockrooms and on the units, so we can make sure our billing is correct and place appropriate food orders.

If you see a Food Services employee, thank them. They work hard every single day, whether it’s summer or a blizzard, a normal day or Phase C, to help make a patient’s or employee’s day better. It’s really about helping people. Being able to do what we do, and see people keep coming back, that’s a joy for me.

What do you like most about working at BMC?
The sense of community is what I like most. The hospital itself is so diverse, but it’s not the type of diverse where everyone is separated. Everyone actually has input and shares and chats with each other. I learn a lot from different backgrounds. I’ve tried so many different types of ethnic food and learned about different religions, holidays, and traditions. It’s really cool to see a community that’s so diverse get along so well.

The things people do here are amazing and our leadership is amazing. We’re a phenomenal hospital. I know we’re the hospital of the future.

What do you do for fun outside of work?
I work with a lot of nonprofits, and do a lot of speaking. I try to give back to the community as much as I can. One of my goals is to start a nonprofit for financial assistance and financial literacy, to show people better ways to deal with money and talk to them about life, because I’ve been through a lot in life.

Do you know a staff member who should be profiled? Send your suggestions to [email protected] .

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New Yawkey Building Spaces Provide Food and Community

In recent months, Boston Medical Center has marked significant construction milestones with the opening of the Moakley addition and the opening of the new Women and Infants Center. In June, the hospital will reach its next major milestone, when the new cafeteria, Demonstration Kitchen, and Preventive Food Pantry open in the Yawkey building.

The Yawkey cafeteria will feature five food stations that provide a unique and distinct variety for anyone eating there. The global station is a flexible set of menu options, each having its own flavors of origin, including Mediterranean Middle Eastern, Asian, Latin, Indian, and Caribbean cuisine. The Italian station will offer everything from pizzas to oven-roasted vegetables to stuffed strombolis, while Grill Nation will allow staff to customize offerings such as burgers, salmon, and grilled chicken. Sono will also allow for customization and combine the numerous ingredients and cooking styles of Latin American food, such as tacos, burritos, and rice bowls. Chef Jet will serve food based on traditional Asian cuisine, including rice and noodles topped with marinated meats and vegetables. There will also be a full salad bar, soup from Au Bon Pain, and daily specials. The cafeteria will have 180 seats, double the capacity of the Menino cafeteria.

The new cafeteria will offer 100 percent grass-fed, antibiotic free ground beef, in collaboration with NELPSC (Northeast Livestock Processing Service Company) a farmer owned and operated company that sources meats from small farms focusing on sustainable and humane practices. This new eco-friendly beef will also be featured on an increasingly sustainable menu that already includes organic produce locally sourced from around New-England, and wild-caught, fresh fish from local fishermen off the coast of Gloucester, Massachusetts. BMC is also partnering with a rooftop garden to provide some produce, and has plans to expand this program in the coming years.

Over the summer, BMC will also roll out QuickCharge, a new payroll deduction option for the cafeterias. Employees can swipe their ID card to pay for their food, and the amount will be deducted from their next paycheck. This service will not only minimize the amount of things employees have to carry with them to lunch, but also increase the speed of service.

“The new cafeteria is a great place for wellness for patients, visitors, and employees.” says David Maffeo, Senior Director of Support Services. “It provides staff with an opportunity to decompress from the challenges of our busy healthcare environment. Retail food operations are so important for employees’ day-to-day working life, and it’s our responsibility and goal to ensure they have an exceptional experience.”

The new cafeteria will also be the new home of the Demonstration Kitchen, which educates patients about nutrition through cooking methods that are compatible with their medical and dietary needs, as prescribed by their physician. The new space will allow the Demo Kitchen to expand its class offerings for both patients and staff and make classes more accessible, with a more central location and sliding glass doors that will open the kitchen to the dining area.

Currently, the Demo Kitchen is open two days a week. The new kitchen will be open five days a week. Tracey Burg, RD, who runs the Demo Kitchen, will teach classes three or four day a week, a pediatric dietician will hold classes, and Morrison, the food services company BMC works with, will also provide programming. Burg is also working to partner with chefs from Boston-area restaurants to have them teach classes as guest chefs and to have staff come in as guest chefs.

“Exposure is one of the biggest benefits of the new space,” says Burg. “Right now, we’re not in a visible location and a lot of providers and patients don’t know we exist or how we work. With the new Demo Kitchen, people will be able see us whenever they are in the cafeteria, and hopefully will want to come to a class, In addition, we will be open more often, which will allow us to have more programming to meet patient needs.”

Regularly scheduled classes will run throughout the week, focused on topics such as cooking for diabetes or hypertension. During these classes, the glass doors will be closed and shaded for privacy. Patients can be enrolled in these classes by their providers or sign themselves up. Staff are also welcome. Burg also teaches classes requested by providers, such as to patients in the Birth Sisters program or for patients with different types of cancers.

In addition to patient classes, Burg runs staff wellness classes that utilize both team building exercises and cooking instruction. For example, groups might have to work together as a team to make a dish using a particular food, and explain why the dish is healthy. Classes for staff are held during the day and in the evening, and Burg is working to hold classes at times that are accessible for different shifts.

Most of the food used in the Demonstration Kitchen comes from BMC’s Preventive Food Pantry, to help patients learn recipes that specifically utilize the food BMC knows they have.

The new Food Pantry, which is approximately 1,500 square feet, is significantly larger than the former location. It will feature more storage space, allowing the Food Pantry to take more and bigger donations, as well as a dedicated walk-in refrigerator and freezer, new equipment, and new furniture for the waiting room. The Food Pantry’s new location will also be easier for patients to access and will improve operations, with convenient access to the loading dock for deliveries and donations.

“We anticipate the number of patients we serve going up in the new space,” says Latchman Hiralall, manager of the Preventive Food Pantry. “We were serving 7,000 patients and family members a month, but those numbers went down to 6,000 when construction started. We think the numbers will at least go back up to 7,000, if not more. Our current space was built to serve 500 patients a month, so having more room will be a big help.”

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Awards and Accolades

Paul Trowbridge, MD, MPH Honored with the 2016 ASAM Late-Breaking Abstract Award
Paul Trowbridge, MD, MPH, an addiction medicine fellow at BMC, has received the 2016 ASAM Late-Breaking Abstract Award from the American Society of Addiction Medicine (ASAM). The award recognizes his abstract presented at the ASAM 47th Annual Conference, which focuses on BMC’s inpatient addiction consult service, and honors the primary author of the submitted abstract that received the highest score during the late-breaking abstract submission period. The selection is made on the basis of new ideas and findings of importance to the field of addiction medicine.

BMC’s inpatient addiction consult service was developed to help engage patients with substance use disorders about their addiction while they are in the hospital, connect them with medication-assisted treatment when appropriate, and educate them about harm reduction and overdose prevent. It provided more than 320 consults in its first six months.

Sophia Dyer, MD, Named One of 14 Most Influential Women in EMS
Sophia Dyer, MD, an Emergency Medicine physician at BMC, Associate Professor of Emergency Medicine and Medical Director of Boston EMS, Police, and Fire, was named one of 14 of the most influential women in emergency medical services (EMS) for Women’s History Month by, an online news resource for the EMS community. Dyer is the first female medical director of Boston’s EMS.