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The BMC Brief

The BMC Brief, Volume 7, Issue 2

February 28, 2018

Successful BMC Program Keeps Moms with Addiction Healthy Before, During, and Long After Delivery

Massachusetts is one of the top states for access to treatment for substance use disorders, especially for pregnant women. MassHealth not only covers inpatient and outpatient care for pregnant women with substance use disorders, but requires that women being treated receive case management support and are seen by a high-risk obstetrician. But even with this support, only 66 percent of pregnant women with substance use disorders in Massachusetts receive treatment before giving birth. Project RESPECT, a Boston Medical Center program that engages pregnant women in recovery, is working to change that statistic.

“Substance use disorder is the highest cause of maternal mortality, even when mothers are in the hospital post-delivery,” says Kelley Saia, MD, director of Project RESPECT. “It’s always a challenge to engage high-risk, high-utilizing patients fully in care, but our goal is to engage them in ongoing recovery treatment. This will be even more important as we move to an ACO model.”

Project RESPECT sees an average of 45 patients a week for medical treatment and counseling. More than 60 percent of Project RESPECT’s referrals come from detox centers around Massachusetts. These patients are admitted to BMC’s high-risk obstetrics service for up to two weeks, where Project RESPECT helps connect them to services and get on medication-assisted treatment. The goal is to find out what patients need and want, but help guide them to treatment.

After connecting patients to appropriate treatment programs, the Project RESPECT team works with them throughout pregnancy and beyond. They act as care providers, a support system, a resource for advice, and an advocate in the legal and social systems when necessary.

Most importantly, Project RESPECT’s work doesn’t stop when the baby is born. While in the past Project RESPECT has focused on getting pregnant women into sustainable treatment, they’ve expanded to focus on the first two years after delivery.

“We’ve spent the last 15 years focused on prenatal care, but it turns out that after delivery is the most dangerous time,” says Saia.

Instead of the traditional six week postpartum check-up, Project RESPECT schedules three appointments – for one week, three weeks, and five weeks out – with new mothers before they even leave the hospital. They then continue to see mothers at regular intervals and check in frequently to ensure that everyone is staying on track. The program's partner in this care is SOFAR, another BMC program that provides support and resources for mothers in recovery and their children in pediatric primary care.

Increasing Follow-Up With a New Pilot Program

Even with the overall success of the program, Saia and her coworkers found that many women who are admitted to the high-risk obstetrics program from detox centers do not follow up for outpatient treatment and other services after they leave the hospital. The follow-up rate for patients has historically been around 27 percent.

To combat this problem, Project RESPECT started a new inpatient rounding pilot program in August 2017 that incorporated peer recovery coaches, all of whom have personal experience with substance use disorders. First, peer recovery coach Cassie Duran, started rounding with patients in addition to the normal rounding by high-risk obstetricians. This took the follow-up rate from 27 percent to 49 percent.

While this was already a significant improvement, Project RESPECT added another layer to the pilot. Saia and Ana Cecilio, RN, began rounding on patients daily, in addition to rounding by the high-risk obstetricians and Duran. In preliminary data, this took the post-hospitalization follow-up rate to 100 percent.

“As providers, we have to build relationships and trust with patients in order to see long-term results,” says Saia. “When we round, patients see familiar faces, which helps build that trust. We can also provide more information and advice about treatment options and social services, which helps patients feel more prepared when they leave the hospital.”

Project RESPECT hopes to formalize this pilot program and is currently working to secure grants to do so. Right now, Saia, Cecilio, and Duran volunteer their time, but the success of the program inspires them to keep going.

“Cassie has literally saved lives,” says Cecilio. “You can’t put a price on that.”

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What do you do, Joanne Hogan?

Name: Joanne Hogan, DNP, RN
Title: Vice President for Population Health, Complex Care Management, Boston Medical Center Health System
Time at BMC: Three months

Q: What do you do at BMC and in the BMC Health System?
A: I oversee the nurse-led complex care management program across the system. My team works alongside physicians and other frontline staff to manage the sickest of our patients, which is a critical component to our MassHealth ACO strategy. We have care management teams at our ACO primary care groups, a few specialty practices, and with some of our other ACO partners.  Given the official launch of the program on March 1, the past months have been focused on recruiting, hiring and training, and integrating our new team members into practice groups.

We are working across all of the members of our Boston Accountable Care Organization (BACO), including Boston Medical Center. The complex care management team at each site consists of a nurse care coordinator, community wellness advocate, and a pharmacist or pharmacy technician. They’ll be embedded into local practices and work with patients in the emergency department, inpatients, and with patients at home and in the community. The nurse will be the clinical anchor of the team, while the community wellness advocate will help us address social determinants of health, like housing, transportation, and food insecurity. The pharmacy component will help us improve medication adherence, education, and access for patients.

The nurse care coordinators will help enroll patients in the program, primarily when they’re admitted to the hospital or in the ED. Those are the most critical and vulnerable times for patients, so it creates an opportunity to engage patients in the program.

Our approach is a caring and open one. We’re first and foremost focused on building authentic, caring relationships with patients. It’s somewhat untraditional in that we’re primarily focused on addressing patient-expressed needs, rather than needs that we identify.

Q: What brought you to BMC?
A: As someone who has worked in this healthcare market for a long time I have always been aware of the unique role that BMC and the whole BMCHS plays in terms of ensuring that the underserved in our communities have access to high quality health care and social services they need. BMCHS is playing a significant role in the MassHealth ACO reform through its partnership with four ACOs. I wanted to be on the front lines of seeing this ACO transformation in action. There is so much innovation and expertise within the hospital and health plan around how best to care for MassHealth patients and I want to be part of leveraging that so that we can have the most impact on the patients and communities we care for. 

Q: You’re in charge of one of the new teams under the ACO model of care. How will the program help us get our patients healthy and keep them well?
A: Population health, broadly, is a holistic approach to health. It goes beyond the medical model of focusing on disease-specific health to looking at social, economic, and behavioral health factors. It sees patients as extensions of their environments and considers their communities as important contributors to health and well-being. The program, and population health more broadly, attends to all those factors.

Our complex care management program will focus on really meeting patients where they are, and attentively and authentically listening and learning what’s important to them. That’s where we begin the intervention. For many people at BMC this is not a new concept as it is at the core of what the hospital has done as evidenced by the myriad of programs that seek to care for the whole patient and address the various barriers impacting their ability to achieve optimal health outcomes.

The complex care management program cares for our highest-risk and highest-utilizing patients, but we think more broadly about what other patients in the ACO need. They may not need the same intensity of services, but can benefit from certain aspects, like better access to resources. We’ll translate our lessons from complex care management to the broader community to focus on population health for all our patients in the ACO.

We are privileged to join patients on their journey and we approach our involvement with them and interactions with them without judgment, with openness and respect. Our goal every day is to build trustful, caring, healing relationships with patients, so that they can be on a path toward more autonomy and control of their health, with our support, to stay well.

Q: What do you like most about working for BMCHS?
A: Across all of our system organizations – hospital, health plan, the physician group and our partner CHCs, everyone is singularly committed to the work of caring for vulnerable populations and that is really inspiring and gives me great confidence in our success in the ACO and our broader population health efforts.

Everyone is so welcoming, not just to me, but to other people contributing to this work. People are generally receptive to the broad and diverse voice and expertise we have here.

Q: What do you do for fun outside of work?
A: I spend a lot of time near the water, especially on the Cape. My family is really important to me. I have two grown children, a husband and large extended family. I also like to travel and take long walks along the beach.

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Think you know the Demonstration Kitchen? Think Again!

Maybe you’ve only seen it while you’re getting lunch in Yawkey. Or perhaps you’ve taken a class, referred a patient, or sampled one of their delicious recipes. No matter how well you think you know the Demonstration (Demo) Kitchen, which has been part of BMC since 2001, we’re willing to bet there’s still more you can learn. Read on for five facts about BMC’s culinary gem.

The Demo Kitchen is now the Teaching Kitchen!

The Demo Kitchen is changing its name! The kitchen will now be known as The Teaching Kitchen at Boston Medical Center. This name change goes along with industry trends, and emphasizes that the kitchen is not just for demonstrations.

“It’s more than that,” said Tracey Burg, head chef and dietitian at the Teaching Kitchen. “We’re not just demonstrating. Everything we’re doing is hands-on nutrition education.”

BMC has recently become a part of the Teaching Kitchen Collaborative (TKC), which is an invite-only network of thought-leading organizations who use teaching kitchen facilities as catalysts of enhanced personal and public health. The collaborative meets twice a year to promote culinary medicine, where health care providers, dietitians, and food scientists all come together to share ideas and best practices.

“It’s all about bringing the culinary world into the medical world,” said Burg. “After all, food is health!”

The Teaching Kitchen extends beyond BMC’s walls.

While the Teaching Kitchen is based in BMC’s Yawkey cafeteria, that’s not the only place they cook up nutritious meals. The chefs, interns, and dietitians frequently travel into the broader community. Every other month, Burg and her team visit the SPARK Center in Mattapan, which is a model childcare program offering comprehensive, integrated, state-of-the-art services for children and families whose lives are affected by medical, emotional and/or behavioral challenges. Burg not only teaches the kids how to cook, but also showcases the different health benefits of the ingredients.

They also visit the Margaret M. Shea RN Adult Day Health Program, also in Mattapan, to work with their participants – 90 percent of whom have diabetes – on boosting their nutrition.

The Teaching Kitchen is an excellent resource for BMC’s patients.

The Teaching Kitchen offers a large variety of classes for patients, and soon, providers will be able to “prescribe” a class through Epic, like they can for the Preventive Food Pantry. Working with a patient who is a cancer survivor? Tell them about the class developed just for them. How about patients struggling with what to cook while treating or preventing diabetes? There’s a class for that, too! From Heart Health to Cooking for Recovery, there are over a dozen classes every week that patients can attend. Some are tailor-made for patients with specific conditions or needs and others are open to all staff and patients. View March’s schedule.

The Teaching Kitchen is a great resource for employees, too!

Want to learn the best way to cut a mango? Wondering about the science behind the coconut oil versus olive oil debate? Always wanted to learn how to make sushi rolls? Burg and her team are available to answer these questions and more. Culinary Skills 101 covers everything from knife skills to new techniques for cooking, all with certified dietitians on hand to answer any culinary questions you may have.

There’s also a chance to show off your own cooking expertise! The Teaching Kitchen hosts Iron Chef Competitions that allow you to challenge fellow staff members on their culinary abilities. How’s that for bragging rights around the office?  Click here to see a schedule of classes open to employees, or email Tracey Burg at [email protected] with your questions or to set up a session. You may even see some special guests around the Teaching Kitchen, which regularly hosts a variety of guest chefs and dietitians.

The Teaching Kitchen partners with BMC’s Rooftop Farm.

With the addition of the Rooftop Farm in 2016 along with the Teaching Kitchen and Food Pantry, BMC now has three key initiatives that promote healthy eating and living. The 25+ different crops grown on the farm provide food for the Preventive Food Pantry, the cafeterias, and the Teaching Kitchen. Fresh produce makes its way into many of the meals prepared in the Teaching Kitchen, and starting during the 2018 season, live video footage in the Teaching Kitchen will show the farm as it grows.

The Teaching Kitchen also teams up with the Rooftop Farm for the Summer Culinary Camp for Kids, a two-week camp available to kids of BMC employees and young patients. The kids visit and pick produce from the farm in the morning, then head down to the Teaching Kitchen to cook meals using what they harvested, learning the true meaning of farm to table.

Want to try out a recipe? Just visit the Teaching Kitchen website to view and print out the recipes you got to taste.

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The Hero of Preconception Care

Health care might have found its Wonder Woman. She can identify health risks in young African-American women and help them successfully resolve those risks. She is engaging, empathetic, culturally competent, and extremely knowledgeable in preconception care. And soon, her advice will be available at any time to participants in a new study at Boston Medical Center meant to overcome factors that are detrimental to black women’s health, like limited physician time and resources.

She can also be everywhere at once because Gabby, a significant healthcare disruptor, is not a real, physical person. The Gabby Preconception Care system, her formal name, is an embodied, online animated character, delivered via computer or tablet. She is programmed and designed to screen young black and African-American women for more than 100 general and reproductive health risks and to help them resolve those risks for before pregnancy.

“Gabby is part of a new effort to focus on engaging young women before they become pregnant – a concept called preconception care,” said Brian Jack, MD, chief of family medicine at Boston Medical Center. “Essentially, healthy women are more likely to have healthy babies.”

Despite decades of research, health disparities in birth outcomes persist for black and African-American women, who are more than two times as likely to deliver a low-birth weight infant as white women. Intervention studies in prenatal care have not been shown to lessen persistent disparities in birth outcomes, and it may be too little, too late in attempts to resolve concerning health disparities. In addition, there has been only modest progress in implementing what is known about preconception care into clinical practice, and little research has been done to translate preconception care knowledge into health delivery systems.

Jack’s team has spent the last six years developing, refining, and studying Gabby to fill that delivery gap in preconception care. She represents a prototype for the future of health care delivery by aligning with current technology and supplementing the care provided by community-based health providers.

Gabby faces her next test in real-world clinical settings at six Healthy Start and six community health center sites. The new study, which is supported by a $1.58 million grant from the Agency for Healthcare Research and Quality (AHRQ), will recruit 60 black or African-American women to interact with Gabby over six to nine months – at times decided by users.

Gabby has been successful in her mission to reduce pregnancy health risks before. In a randomized control trial, Gabby identified and successfully resolved health risks by more than 25 percent compared to a control group. Almost two-thirds of participants in the trial reported they used information from Gabby to improve their health, and another 22 percent planned to do so in the future.

“Gabby’s ability to deliver content in a simple, conversational style is the closest person to person communication a device can provide. Her nonverbal conversational behaviors also enhance recall of critical information, as education is the key to the Gabby System and mitigating health risks,” said Jack, who is also a professor and chair of the department of family medicine at Boston University School of Medicine.

The content of the Gabby system is tailored to women’s desired outcome and is based on the Centers for Disease Control and Prevention “Content of Preconception Care.” For example, Gabby can tell the difference between women who are interested in pregnancy prevention versus women who want to become pregnant. Gabby delivers specific health behavior change dialogue using techniques like motivational interviewing and shared decision making.

Subjects in the study will be able to create a “My Health to-Do List” during and after their interactions with Gabby, which they can share with their medical providers. Post study, Jack plans to release an implementation toolkit to facilitate broader dissemination of Gabby.

“The Gabby System is designed to extend the patient-provider conversation beyond the office,” Jack said. “Gabby won’t replace the interaction between patients and providers, but instead serves as a catalyst for discussions between them. She’s another resource that can be offered by providers to ultimately facilitate the invaluable, and often time-consuming work clinicians intend to accomplish with their patients, but do not always manage to do so.”

More information on the Gabby System and study grant can be found on AHRQ’s website.

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Awards and Accolades

CATALYST Program Honored for Innovative Approaches to Adolescent Health Care

The CATALYST Program at Boston Medical Center has received the 2018 Hilary E.C. Millar Award for Innovative Approaches to Adolescent Health Care from the Society for Adolescent Health and Medicine. The award recognizes original and innovative programs that predominantly focus on adolescent health care.

Joseph Kaserman, MD, Receives John W. Walsh Translational Research Award

Joseph Kaserman, MD, a physician in Pulmonary, Allergy, Sleep, and Critical Care Medicine, has been named as the first recipient of the John W. Walsh Translational Research Award in Alpha-1 Antitrypsin Deficiency. The award provides money for the winner to continue innovative research on alpha-1 antitrypsin deficiency, a genetic conditions that can lead to lung or liver disease. 

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News of Note

BMC’s Cancer Center Reaccredited

BMC’s Cancer Center has been reaccredited by the Commission on Cancer for three more years. Accreditation recognizes the Cancer Center’s commitment to comprehensive and patient-centered care, a multidisciplinary approach, clinical trial access, lifelong patient follow-up, psycho-social support, and continuous quality improvements.

BMC at the First Event Transgender Conference

BMC was a sponsor of the 2018 First Event Transgender Conference, one of the oldest and largest transgender conferences in the world. In addition, several BMC employees – Jeffrey Spiegel, MD, chief of the Facial Plastic Surgery Program, Wendoly Langlois, associate general counsel, and Pamela Klein, nurse liaison to the Center for Transgender Medicine and Surgery – presented during the conference.

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