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May 2016 Volume 3, Issue 1

From the Desk of Kate Walsh

Healthcare is changing. We read about it in the news, talk about it at the water cooler, and see it in action when we visit our own caregivers. Boston Medical Center is changing, too. Our clinical campus redesign is well underway and we're working to make our spaces more efficient, effective, and accessible, so that we can continue to provide the highest quality care for all of our patients well into the future.

As Boston Medical Center's physical space transforms, we're also changing the way we work. Our mission to provide exceptional care increasingly extends beyond the walls of BMC. Technology plays a significant role – from a new electronic health record system that integrates and streamlines communication between hospital and community-based caregivers to a mobile app that connects patients and clinicians on-the-go. Simultaneously, the creativity and dedication of the BMC community remains our most valuable resource – from an innovative program to promote family financial wellness to a peer-to-peer support network for parents of children with autism.

In this issue, we're highlighting some of the many ways that BMC is readying for the future while continuing to promote the overall wellness of our patients and families both in and out of the exam room.

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At BMC, Patients Receive Help with Financial Wellness Too

Each year, millions of Americans sit down to file their taxes. While most of us make it through this process easily enough, many others miss out on tax credits and refunds they are entitled to. For some BMC patients, the money they can get through those credits can be a lifeline to financial – and overall – wellbeing. This year, a new program called StreetCred is helping BMC patients file their taxes and benefit from the refunds they are entitled to.

StreetCred began in 2015, when Lucy Marcil, MD, MPH, and Michael Hole, MD, MBA, both second year Pediatrics residents at BMC, realized that they could make a difference in their patients' health not just through medical treatment, but also by helping families address the poverty that underlies many health issues. Both began asking their patients what would be most useful for BMC staff to help with, and found that free tax help would be a welcome way to get families more money.

Many BMC families are eligible for the earned income tax credit, which is the third largest federal social welfare program, after Medicaid and food stamps. However, 20 percent of eligible families don't take advantage of the credit, which can lead to a refund of up to $6242 (the average is $2400). In addition, many families who do get the credit pay for someone to prepare their taxes, an additional expense.

"There's evidence that the earned income tax credit is linked to better health outcomes," says Marcil. "Various studies have shown that families who receive this credit have lower smoking rates and lower infant mortality, for example. Helping families at BMC get this credit is a simple intervention that makes their lives easier without much effort on their part, and that can have a real, positive effect on our pediatric patients. It also helps patients feel more connected to their providers beyond office visits."

StreetCred, which officially began in January and ran through tax season, was carried out by five part-time StreedCred staff members, a part-time BMC program coordinator, and 20-30 active volunteers. Staff members and volunteers called families with appointments in Pediatrics before their visit and invited them to make a StreetCred appointment. They also ensured that patients knew what documents they needed to bring. When patients arrive at their StreetCred appointment, they fill out an intake form to confirm their eligibility – StreetCred can't help with very complicated taxes – and can either sit with the volunteer tax preparer or have their tax returns completed while they visit with their clinician. It takes volunteers approximately 20 minutes, depending on the complexity of the return, to complete federal and state returns using an electronic filing system. Completed returns are reviewed by another volunteer and by the client, then filed.

As of mid-April, StreetCred had filed returns for more than170 BMC families. This has led to approximately $400,000 in returns, including more than $90,166 from the federal earned income credit.

"We learned a lot about how to reach families," says Marcil. "Many families we spoke to had already paid to have their tax returns filed, so next year we definitely plan on reaching out earlier. We also had many people hear about StreetCred through word of mouth, so we plan on taking greater advantage of that."

Prior to starting StreetCred, Marcil and Hole both had experience with health-related finance programs, but neither were well-versed in taxes. To prepare, they partnered with the Boston Tax Help Coalition, a partnership of nonprofits, businesses, and community organizations that provides free tax preparation assistance and financial education to low and moderate-income Boston residents. One way the Coalition does this is by administering Boston's federal volunteer income tax assistance (VITA) grant at 37 sites around the city. In order to provide tax assistance to patients, BMC became a registered VITA site – the first at a hospital.

Marcil and Hole plan on offering StreetCred again next year, with expanded services, such as offering more financial services and in clinics besides Pediatrics. They also would like the model to be replicable, and are working on formalizing a toolkit that can be used by other hospitals. Currently, they are spreading the word about StreetCred through the national network of residents and exploring expanding the program to other Boston hospitals.

"StreetCred envisions a healthcare system that can help fill basic resource needs for all families raising children," says Hole. "Pediatric clinics can be extremely valuable as one-stop shops of anti-poverty tools so every family visiting has the resources it needs to raise healthy kids. What an incredible gift it has been that BMC shares this vision."

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Electronic Medical Record Links BMC and Community Health Centers

With its implementation of an Epic electronic health record (EHR) complete, BMC now has a single, unified health record for each patient, creating a more efficient and cost-effective system that will lead to better outcomes. Now, BMC is working with Boston HealthNet – the network affiliation of BMC, Boston University School of Medicine, and 13 community health centers (CHCs) – to implement Epic in nine CHCs, further uniting BMC with its community health affiliates and creating a more integrated system for care delivery.

In 2014, Boston HealthNet began evaluating new electronic health records to implement at the CHCs, with a key goal being better communication between the CHCs and BMC. Boston HealthNet selected a platform called OCHIN, an Epic system with the same core functionality as other Epic electronic health records, but specifically designed for community health centers.

The OCHIN implementation began in November 2015 at South Boston Community Health Center and the Greater Roslindale Medical and Dental Center. Implementation has also been completed in Mattapan Community Health Center and Codman Square Health Center. OCHIN went live at Dot House Health at the end of March, and will go live at South End Community Health Center in May, Upham's Corner Health Center and Whittier Street Health Center in June, and Boston Healthcare for the Homeless in August.

The new system has a variety of benefits for both BMC and the community health centers. Previously, CHCs could not easily share information with each other or with BMC, and the information that could be shared was limited and not well-integrated into patient charts. A shared Epic platform allows for better communication between BMC and the CHCs because it allows the systems to "speak" to each other.

OCHIN also improves the referral process between CHCs and BMC, enhancing care coordination and providing patients with timelier access to specialty care. BMC physicians receive CHC referrals quickly and in the same system that BMC doctors use internally. Eventually, the system will also allow referring providers to see the status of the referral and when the visit took place. BMC and Boston HealthNet are the first in the United States to implement this Epic referral module.

This higher level of communication between providers at BMC and at CHCs will also help streamline the coordination of data for patients with multiple providers. Because caregivers can easily see what other providers have done, the likelihood of unnecessary or repeated tests or exams will decrease.

With OCHIN and eMERGE, providers at the community health centers know that their patients will be seen at BMC quickly and that they will have timely access to patient data. Similarly, providers at BMC can get data to CHC providers more easily, which in turn will enhance continuity of care.

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Grow Clinic Wins Nick Littlefield Award for Excellence in Community Health

On April 26, health care and government leaders gathered at the Edward M. Kennedy Institute for the United States Senate to honor Boston Medical Center's Grow Clinic with the Nick Littlefield Award for Excellence in Community Health. The Grow Clinic, which is run by Deborah Frank, MD, was selected as the inaugural winner of the award by the Blue Cross Blue Shield Foundation. As the winner, the Grow Clinic will receive $50,000 per year this year and in 2017 – a surprise change in the award, which was slated to be for one year only.

The Nick Littlefield award was created to recognize an organization that is making extraordinary contributions to the health of low-income and vulnerable children. It honors the lifelong dedication of Nick Littlefield, Senator Edward M. Kennedy's Chief of Staff for the Senate Health, Education and Labor Committee, to public health policy. The money received by the Grow Clinic will help fund a program that assesses families for extreme housing insecurity and connects them to necessary services and affordable housing.

Since its inception in 1984, BMC's Grow Clinic for Children has become a national model for the treatment of malnutrition in inner-city children. The Clinic provides comprehensive multidisciplinary care, including medical, nutritional, social services, and dietary assistance, to children from the Greater Boston area diagnosed with failure to thrive. These children have significant difficulty growing because of malnutrition associated with poverty, family stress, and illness, which can often lead to delayed cognitive development, emotional problems, and frequent and serious illness.

"Dr. Frank's unwavering commitment to providing health care to vulnerable children and the gains she's made are so very deserving of this award," said Littlefield in a statement read by his daughter. "We wish her and the Grow Clinic another 30 years of helping kids thrive."

"I am deeply honored on behalf of my colleagues and Boston Medical Center," said Frank. "This grant underlies that there are leaders who recognize that hunger and housing are two demons threatening the wellbeing of America's children, who are some of the poorest people in the country."

Megan Sandel, MD, a faculty physician at the Grow Clinic, also spoke at the event, saying "when we think about innovation, we usually think about a pill or new technology, but sometimes innovation is about finding kids somewhere to sleep for the night. This award will help us innovate in that space – where Dr. Frank has set the standard – and create the healthiest generation of kids in Massachusetts."

The final speaker of the event was Congressman James McGovern, who is currently serving his tenth term in Congress. There, he has taken a leadership role in the fight against hunger at home and abroad.

"No one in this country is invisible to Nick Littlefield or to Dr. Frank," said McGovern. "Everyone who goes to the clinic gets the very best care not just in the country, but in the world. I can think of no better recipient than the Grow Clinic for this inaugural award."

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Autism Program Helps Parents Help Each Other

BMC has a wide variety of resources to help our patients and families. One of our greatest resources, however, is our patients and families themselves. Recognizing this fact, BMC's Autism Program created the Parent Leadership in Autism Network (PLAN), an initiative that trains and empowers parents of children with autism to help support other parents of children with autism.

PLAN began three years ago when Shari King and Lauren Bartolotti, the program director and coordinator, reached out to clinicians, local schools, and other professionals to find parents interested in helping others, with the goal of creating a network of parent leaders. The pilot group was intentionally small, at six parent leaders, and in 2015 more than tripled in size to twenty-five.

"The parents we talked to didn't necessarily identify themselves as parent leaders, but all have a child with autism and have been incredible advocates for their children," says King. "While staff in the Autism Program at BMC always aim to provide the best support to families, we know that there's no substitute for parents connecting with one another. We learn so much from our parents every day and their sharing of insights, expertise, and their own experience are gifts that they can give to one another through this program."

The parent leaders are trained on a variety of topics, including how to communicate, how to give advice and listen effectively, boundary setting, how to navigate complex needs, and training on specific resources. PLAN staff also help parents realize their own areas of expertise, which come largely from their own experience, including communication strategies, dealing with difficult behaviors, navigating transitions and advocating for educational and therapeutic services.

Once parent leaders are trained, they are matched with families who have signed up for the program. Families from the community – PLAN serves the entire Boston area, not just BMC – can be referred by a community organization, a clinician or resource specialist, or refer themselves to the program. Program facilitators help determine the best parent leader match, based on the needs of the family. The program makes 10-15 new matches a month, and some parents end up speaking with multiple parent leaders as greater needs emerge.

PLAN allows parent leaders and the family receiving support to identify the level of support necessary and the best way to communicate. Most parents use phone or email, but some meet in person. Support can range from referring the family to a support group to talking over the phone a few times to developing friendships.

"BMC patients face many complex issues, such as homelessness, exposure to violence, and linguistic and cultural barriers," says King. The role of the parent leader is to provide support around the challenges of having a child with autism and when a family needs support in other areas, we will help the parent leader refer the family to the right place."

Parent leaders also meet once a month to provide support for each other and get help with difficult situations. This ongoing training and support helps ensure that parent leaders are well equipped to handle any issue that might come their way. Parent leaders benefit not only from relationships with the families they support, but also from their relationships with each other, which is a critical and unique part of the program. While there are formal trainings once a year for parent leaders, parents who are interested in becoming leaders can join these meetings before being trained, and the program will assess whether or not they are ready to take on matches.

"Many parents who have been helped have expressed interest in becoming parent leaders themselves," says Bartolotti. "It's great to see that PLAN can help empower parents to recognize their own potential. We're always trying to grow the group and expand its diversity. Some parents take on important roles within the program in addition to serving as a parent leader, such as managing social media outlets, fundraising, or working as the match coordinator."

Currently, there are 23 active parent leaders who represent a range of cultural and linguistic backgrounds – they speak English, Haitian Creole, French Creole, Arabic, Mandarin, and Spanish – and have children with autism who range in age from toddlers to adults. The cultural diversity of the parent leaders is an asset to the program, as parents are able to talk about not just what having a child with autism is like, but what it's like to have a child with autism within a specific culture.

"Massachusetts has better resources than many places, but they are still not ideal," says King. "Parents of cultural minorities can be particularly isolated, and we aim to help them overcome some of that isolation. Our parents are driven to create groups and services that work for them. We want PLAN to be a place where families are served and connected to a much bigger network outside of ours, where they can go on to have a continuous home for themselves and continue to meet their changing needs."

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Building a Campus for BMC's Future

In 2015, Boston Medical Center completed the first major project in our multi-year campus redesign with a significant addition to the Moakley building. This year will be an even bigger year for construction at BMC, as multiple projects across campus will be finished or get underway by the end of 2016. The opening of each new space will improve resources, services, and overall experience for patients and employees.

While each completed project and move brings benefits for patients and staff, the most significant impact will come at the end of construction, when hospital operations and services are consolidated onto one campus. At that point, the hospital will realize substantial operational and financial gains through the efficiencies of a single campus, totaling $25 million annually. This will include $8 million per year in energy savings, and moving most of the energy loads of the hospital to solar and wind power.

"Our clinical campus redesign is a huge undertaking that will serve as the foundation for BMC to continue as a health care leader for years to come," says Kate Walsh, President and CEO. "Our employees will have more modern, comfortable spaces to work and provide care, and when the redesign is finished, we will have the newest facilities in Boston. This updated space is key to our commitment to be the best place in the city to work and receive care."

The first major opening of 2016 was the Women and Infants Center, located on the fourth floor of the hospital's Yawkey building. The new Center brings together the Ullian Neonatal Intensive Care Unit (NICU), Labor and Delivery, and all other hospital services for women from prenatal to postnatal care, in a modern and comfortable setting for mothers and babies.

"This project required an enormous commitment of time, resources, and energy from colleagues across the hospital," says Nancy Gaden, DNP, RN, NEA-BC, Senior Vice President and Chief Nursing Officer. "We have created a beautiful new facility for our patients and families. Through this and other projects, we're bringing everyone at BMC, from clinicians to volunteers to support staff to patients, into the future. That's the best part of this."

In June, the new Yawkey cafeteria and Demonstration Kitchen will open and BMC's first-in-the-nation prescription Food Pantry will relocate to its new space. The cafeteria will be a welcoming, inviting space for employees to gather, while the new Demonstration Kitchen will expand BMC's popular classes on healthy, nutritious cooking techniques to a wider audience. The Food Pantry, originally built to serve 500 patients a month, currently serves 7,000. The pantry provides food that is specially tailored to patients' medical needs, as prescribed by their physicians. The new space will accommodate the Food Pantry's space needs and greatly increase the number of patients it can serve.

Construction will continue through the summer, and the patient transport bridge over Albany Street will be completed in early fall. The transport bridge project began in December, when the new bridge was raised over Albany St. The bridge weighs 104 tons and was lifted by two 275 ton cranes. The yellow tube currently over Albany Street is slated for removal following the opening of the new transport bridge.

By the end of the year, BMC's campus redesign will be primarily focused on the Menino Pavilion. Construction in Menino is expected to be complete in 2018.

"We strive to provide efficient, high-quality, and low-cost care for patients at BMC," says Ravin Davidoff, MD, Chief Medical Officer. "With the redesign, we have an incredible opportunity to build the type of space that will allow us to reach our goals and provide the right care to patients. BMC has always provided exceptional care, and our new space truly shows our commitment to getting it right for every patient who comes here."

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BMC Awarded $2 Million NIH Grant for Study of Ambulance Diversion

Boston Medical Center has been awarded a $2 million grant from the National Institutes of Health's National Heart, Lung, and Blood Institute to study the impact of ambulance diversion on the outcomes of low-income patient populations across the United States. It is the first study of its kind to be funded by the NIH.

Ambulance diversion is the practice in which emergency departments are temporarily closed to patients transported by ambulance. Massachusetts is the only state that has banned these diversions, which the Institute of Medicine has characterized as "antithetical to quality medical care." Using the ban in Massachusetts as a natural experiment, the study aims to examine the impact on timeliness and quality of care for ED patients transported and not transported by ambulance.

"As a safety-net hospital, BMC sees a higher percentage of low-income and vulnerable patients than many of our hospital peers, and many of these patients come in by ambulance," said Amresh Hanchate, PhD, of the department of general internal medicine and assistant professor of general internal medicine at Boston University School of Medicine, and a co-principal investigator of the study. "When emergency departments go on diversion, turning away ambulances transporting patients, care is delayed, sometimes significantly, which can have a detrimental impact on patient outcomes."

Using Medicare data, researchers will identity a national cohort of random Medicare beneficiaries age 66 or older with a chronic cardiovascular or pulmonary condition, with an oversample from Massachusetts, and will obtain data on all healthcare utilization, including ambulance and non-ambulance ED visits from 2006-2012. The study is a collaboration of researchers in general internal medicine and physician-researchers in emergency medicine at BMC, as well as emergency medical services in Boston.

In the last published survey in 2003, 45 percent of US emergency departments, and 70 percent of urban emergency departments in the US reported ambulance diversions. Diversion is associated with higher patient mortality, delayed treatment, and other adverse outcomes, with in turn the potential to increase health care costs.

"Massachusetts' decision to ban diversions in 2009 was the right thing to do, as it did what all hospitals and caregivers should be doing – putting the patients first. Our goal with this study is to show how diversions impact patient care, with particular emphasis on race/ethnic and low-income populations, so that more states will realize the wide-ranging benefits of banning these diversions," said co-principal investigator James Feldman, MD, MPH, of the department of emergency medicine at BMC and professor emergency medicine at BUSM.

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Hypertension? There's an app for that.

Nowadays, people use smartphones for everything from getting a ride to watching movies, and taking care of their health is no exception. BMC doctors and researchers have now made it easier for patients trying to lower their blood pressure with an app that provides guidance on using the DASH diet. The app is currently being tested in a pilot study.

The DASH (Dietary Approaches to Stop Hypertension) diet helps people with hypertension control their blood pressure through healthy, yet flexible, eating. It provides daily and weekly nutrition goals for eating specific numbers of servings for different food groups, such as four to five servings of vegetables, six to eight servings of whole grains, and two to three servings of fats and oils per day.

"The DASH diet is a good, evidence-based way to reduce blood pressure, but is not implemented widely," says Devin Mann, MD, Associate Chief Medical Information Officer for Innovation and Population Health at Boston Medical Center, and one of the creators of the app. "It can be hard to promote within the health care system, because we can really only refer patients to nutritionists – which can be too time-intensive for many patients – or to books. The app was created to help overcome resource issues like patients not having enough time with trained experts as well as logistical barriers, because it allows patients to connect on their own time."

Three years ago, after attending an NIH seminar on mobile technology in health care, Mann saw an opportunity to expand on Boston University's employee-focused "DASH for Health" program with a mobile component geared toward patients. He began working with informatics fellows and Lisa Quintiliani, PhD, a BMC behavioral scientist, to develop an app that would help patients stick to the DASH diet. Now in its second iteration, the app is currently being piloted.

The DASH pilot consists of two connected parts: the app and health coaching. Patients are given Bluetooth-enabled devices to measure weight, blood pressure, and steps; these devices sync to the app to allow patients to track their progress more easily. The app also asks patients to input basic information about their diet, such as how many servings of DASH-approved foods they ate on a given day. All patients use their own smartphone for the program.

The coaching aspect of the program is also integrated into the app. Patients talk to their health coach every two weeks, but in-between those phone calls, coaches – who can see all the data patients input into the app – use the app to connect with patients. They can recommend articles to read or videos to watch, post encouraging comments, and reinforce good behaviors. For the biweekly phone calls, coaches have a script outline that utilizes motivational interviewing techniques to guide patients through making lifestyle changes. While coaching currently is done by dietitians, the researchers are considering a peer counselor or patient navigator model after the trial.

"Humans and computers are good at different things, and the goal of having both human coaches and the app is to utilize all of those skills," says Quintiliani. "The coaches are good at listening and responding in real time, as well as promoting self-confidence and providing motivation. Computers are good at gathering and analyzing data, finding resources, and displaying information. These skills are all necessary to help patients align their actions with their personal values, such as becoming a healthier person so that they can play more with their children."

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Accessibility Initiatives Make BMC Inclusive for All

Walking around BMC's campus or hopping on an exam table might be easy for many patients, but for some, particularly patients with disabilities, small tasks associated with receiving care can be much more difficult. At BMC, hard work is happening all over the hospital to ensure that all patients, regardless of ability, are able to receive the care they need.

"It's important to ensure that all patients have equal access to care and that we can meet the unique needs of our broader patient population," says Kristen Kremer, MPH, one of the leaders of the work.

BMC works in partnership with the Boston Center for Independent Living (BCIL) to identify and address accessibility issues across campus. This partnership began in January 2014 with a memorandum of understanding aimed at making BMC the most accessible hospital in Boston. BCIL and BMC together received a Workforce Transformation Fund training grant from the Commonwealth Corporation and have created a video for staff that shows how to serve patients with disabilities, specifically focused on communication. The goal is to appropriately train all staff members in how to communicate with and care for patients with disabilities and empower those patients to take part in their own care.

"Our partnership with BCIL is unique," says Kremer. "Because of their work, we are able to learn about best practices and hear more voices of patients with disabilities. Their expertise helps us think through barriers to care and what works or doesn't work to overcome these barriers. We are also working to involve patients with disabilities more directly in our work, to ensure that the patient voice is fully present as we move forward."

Through both the partnership with BCIL and other initiatives, BMC has made numerous strides to improve the accessibility for patients with disabilities. The BMC Accessibility Committee was established in 2013 to conduct a comprehensive assessment of the access that BMC patients with disabilities have to health care, including the physical buildings, the availability of accessible medical equipment, policies and procedures, employee training, communication development, aids and services, and community outreach. The goal was to examine BMC's level of accessibility for patients with disabilities and undertake the work necessary to improve that access.

BMC has also implemented wheelchair return locations to make sure wheelchairs are always available for patients who need them, updated policies and procedures related to patients with disabilities, and held trainings on improving the care experience for patients with disabilities. A multidisciplinary hospital group is spearheading the selection of accessible exam tables and other medical equipment for the hospital, incorporating feedback from staff and patients into the process.

With a major overhaul of BMC's campus underway, BMC is working to ensure that new spaces are accessible for everyone. A group of external surveyors and BMC's construction team collaborated to determine Americans with Disabilities Act (ADA) compliance in BMC's buildings and to incorporate their findings into new buildings. The initial survey identified 2,015 barriers to accessibility at BMC, ranging from wheelchair shortages to door handles that are difficult for patients with disabilities to use. Over the past two years, 816 of these barriers – 41 percent – have been eliminated. As the campus redesign project further transforms BMC, most of the remaining barriers will be eliminated to make BMC a truly accessible place for all patients.

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