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October 2015 Volume 2, Issue 2

From the Desk of Kate Walsh

Recently, Boston Medical Center was featured, along with Massachusetts General Hospital and Brigham and Women's Hospital, on Save My Life, an ABC News medical documentary focusing on trauma care. For six weeks, our medical community was in the national spotlight, and I'm very proud of the fact that people across the country had a window into the amazing caregivers and excellent clinical care provided at our hospitals.

Save My Life made our work more visible than ever, but there is important work happening around BMC every day and so many critical programs that aren't always in the limelight. Programs such as the two we offer for refugees and the Birth Sisters program for vulnerable mothers-to-be are crucial to the patients they serve and are among the many at BMC aimed at the needs of underserved and often invisible patient populations. You'll read about them in this issue, along with unique innovations to prevent costly injuries and hospitalizations and a novel model for caring for children with complex medical and social needs.

The strength of medical care is not only in the major interventions like the ones shown in Save My Life, but also in seemingly small actions, from care that's given in a patient's native language to a follow-up phone call to ensure a protocol is being followed or a prescription is being taken. These small actions happen every day, many times a day at BMC, and serve to make our patients and community stronger and our care better. These small actions aren't usually the ones that get recognized on television, online or in print, but they are no less important to us and our patients.

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BMC Programs Provide Range of Services, Care for Refugees

In recent months, the news has been filled with stories of refugees from the Middle East fleeing to Europe to escape violence and poverty. These stories can make many of us feel helpless, but two programs at Boston Medical Center, the Boston Center for Refugee Health and Human Rights and the Immigrant and Refugee Health Program, have long taken an active role in helping refugees, immigrants, and victims of torture.

Detail from mural in Center for Refugee Health and Human Rights

Each year, over 2,000 refugees arrive in Massachusetts seeking a new life and needing health care and social services. Often they are referred to BMC, one of the only hospitals in Boston to offer health care programs targeted to this population. One such program is the Boston Center for Refugee Health and Human Rights.

The Center was founded in 1998 and grew out of a small mental health program for refugees at BMC. Center staff work primarily with torture survivors and their families, who are referred to BMC through word-of-mouth, other health professionals, resettlement or other community agencies, or asylum lawyers. In 2014, the Center served more than 350 patients from 43 countries, primarily African nations.

The Center provides a wide variety of services to patients, including mental health services, primary health care, obstetrics and gynecology, medical and mental health evaluations for asylum claims, case management, career development, and English classes. All services are provided on site at BMC, but patients may be referred to community agencies closer to home if they prefer.

"Our services evolved organically in response to our patients' needs," says Lin Piwowarczyk, MD, MPH, Director and Co-Founder of the Boston Center for Refugee Health and Human Rights, who is also President of the National Consortium of Torture Treatment Programs. "We are concerned with the well-being of torture survivors and their families who have been through great suffering, and we want to be part of the process of their healing by supporting them using a holistic and multidisciplinary approach."

One patient who was helped by the Center is Shakira, who had to leave her family and come to Boston from Uganda. She began working with Piwowarcyzk three years ago, after her asylum application was delayed and she wanted to find a job in Boston. Shakira is now in nursing school, which she applied to with the help of the Center.

"Dr. Lin helped me with a lot of things," says Shakira. "I was going through a depression then. My family back home had a lot of troubles, and I was crying all the time and had sleepless nights. I told her about all of it, and how I was tortured back home. She helped me move forward and focus on the future. I'm so grateful that I came to BMC. If I hadn't, I wouldn't have been able to cross that line and live in the moment. I felt like my life had come to an end, but Dr. Lin talked me through everything. She helped me accept that this is my home here and helped me focus on how to make it my home. I'm a better person now."

Refugees can also receive primary care services at BMC's Immigrant and Refugee Health Program, which also serves as a gateway to other services. The program runs a weekly primary care clinic and sees 1,500 patients each year. The program also provides consultation for other caregivers who have immigrant or refugee patients. The top countries these patients come from are Iraq, Haiti, Afghanistan, and Somalia.

"Having a refugee health clinic embedded in primary care is unique," says Sarah Kimball, MD, a primary care physician who works within the Immigrant and Refugee Health Program. "Patients get looped into the broader primary care system, and are provided with a 'home' at BMC. For most patients, this is their first exposure to the U.S. health system, so it's crucial they receive culturally sensitive care and are able to see providers who can direct them through the rest of the health care system."

The program currently has seven residents and will have eight next year, along with two preventive medicine fellows. Residents come from primary care, global health, and urban health, with the goal of learning about medicine and human rights in a clinical context.

In addition to basic primary care services, Kimball and Sondra Crosby, MD, also a primary care physician who founded the Immigrant and Refugee Health Program and who has served as a consultant to Physicians for Human Rights, provide support to patients seeking asylum in the US, performing medical evaluations, and psychological evaluations in conjunction with BMC psychiatrists, to document human rights abuses.

Both the Boston Center for Refugee Health and Human Rights and the Immigrant and Refugee Health Program also provide obstetric and gynecological services to refugees, many of whom have concerns about infertility and pelvic pain or are seeking female genital mutilation repair. The programs also work closely with two birthing programs: the Birth Sisters program and walk-in birthing classes open to anyone at BMC. Birth Sisters provide one-on-one support during late pregnancy, delivery and postpartum. The program is also open to all pregnant women needing extra support at BMC, but being a new immigrant is one of the criterion to join the program, so many participants are refugees.

"We have all learned to understand what our patients went through to get here, both logistically and mentally," says Kimball. "By providing a medical home and safe space for refugee patients, we are able to ease their transition to the United States and support them through whatever issues they may have."

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Birth Sisters Help Vulnerable Women through Pregnancy and Childbirth

Pregnancy and childbirth can be joyful times in a woman's life, but they can also be scary and anxiety-producing, especially for women who lack support through this journey. The Birth Sisters program at Boston Medical Center aims to reduce anxiety, improve birth outcomes, and empower and educate women through the support of other women during pregnancy, childbirth, and postpartum.

The Birth Sisters program was founded in 1999 after midwives at BMC noticed a need for a community-based program that would help pregnant women through the process of childbirth with the added comfort of working with another woman from their own community or country. To start the program, the midwives began recruiting and training Birth Sisters from communities that reflect the diversity of BMC.

Obstetrics providers refer their most vulnerable patients, usually in their third trimester of pregnancy, to the program; some of the criteria include social isolation, being a victim of domestic violence, and being a recent immigrant or refugee. The program serves 20-25 women per month and currently employs 18 Birth Sisters. The Birth Sisters speak 10 different languages, with the most in-demand being Spanish.

While some of the Birth Sisters come to the program already certified as doulas (a trained professional who provides support to a mother before, during, and just after birth) most are not. All Birth Sisters receive 24 total hours of training. The training teaches the Birth Sisters not only practical skills, such how to provide labor and breastfeeding support, but also introduces them to different types of birth around the world and teaches how culture affects giving birth, according to Poema Dauti, who has been a Birth Sister for seven years.

"We have Birth Sisters who have been here since 2000," says Dona Rodrigues, a certified nurse midwife who directs Birth Sisters. "To me that shows their passion and their commitment, because it's not an easy job. Home visits can be challenging, labor is long and birth can come at any time. These women have a passion for birth and to help other women, because you need that passion to do this type of work."

Birth Sister assignments consist of one or two prenatal home visits, providing emotional and physical support during the labor process, and go on one or two postnatal home visits for each woman they support. They provide pre-and-postnatal education, including breastfeeding and birth control education. Birth Sisters also assist the mother around the house with chores or cooking or bathing the baby if necessary, and help facilitate the mother's medical care and connect the mother with any social services she might need, such as food stamps. The women who use the program can also be set up with community and educational resources to provide them with new skills.

The Birth Sisters program is also linked to better outcomes for the children born to mothers who use the program. For example, peer counseling has been recognized as one of the few effective interventions for raising breastfeeding rates among minority and low-income women. On average, breastfeeding rates for these groups across Massachusetts are between 60 and 70 percent; the breastfeeding rate for women who use the Birth Sisters program is 81 percent. In addition, the program helps prevent complicated births by getting women appropriate prenatal health care. This has been linked to fewer Cesarean sections and neonatal intensive care unit (NICU) use. The average cost of a C-section in Massachusetts exceeds $20,000, and the average cost of a day in the NICU is $3,500. Just preventing only one C-section would pay for Birth Sisters services, at about $700 per birth, for nearly 30 women.

"The most rewarding part about being a Birth Sister is the moment when the baby is born, when you get to hear him cry and look at the healthy baby and see how happy the parents are," says Dauti. "I'm very thankful all the time that I get the opportunity to share those important moments. And to see that Birth Sisters are appreciated makes me want to help even more women."

Another goal of the Birth Sisters program is to help and encourage women who serve as Birth Sisters to receive further education and job training. A popular option is nursing, and last year three Birth Sisters finished nursing school. Midwifery and public health are also popular professions. According to Rodrigues, the program helps Birth Sisters gain other BMC jobs if they choose to pursue them.

"The commitment of the Birth Sisters to other women in the community is outstanding," says Rodrigues. "We see women really establish sister-like relationships with the Birth Sisters and they end up friends for life."

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SPARK Center Serves Boston's Most Vulnerable Children

Boston Medical Center has a long history of serving vulnerable populations of all ages, including children. Children who are at highest risk are served by the SPARK (Supporting Parents and Resilient Kids) Center, which provides comprehensive therapeutic day services for infants, toddlers, and preschoolers with complex medical and psychiatric needs.

SPARK, which is the only center of its kind in New England, was founded in 1989 by the Boston Public Health Commission as the Children's AIDS Program. In 1995, it became part of BMC (then Boston City Hospital). The center serves approximately 60 children from birth to age 24 annually, most of whom are living in poverty. SPARK's unique program provides an alternative to expensive daytime treatment options for these children, while helping to stabilize families who are often marginalized and struggling to maintain jobs and housing. Services provided by SPARK include nursing care, early education and intervention, care coordination, intensive behavioral health services, family engagement programs, and end of life care. SPARK also runs a program, TICKET to Success, which serves young adults in transition who have complex medical needs, providing participants with job training, treatment adherence counseling, social support, adult life skills, and educational support. Some TICKET youth also work with younger patients in SPARK classrooms.

"The kind of child that SPARK serves typically has multiple health challenges, as well as developmental and emotional challenges, which can accompany health problems," says Martha Vibbert, PhD, Executive Director of the SPARK Center and faculty member in Psychiatry and Pediatrics at BU School of Medicine. "For example, SPARK has extensive expertise in caring for very fragile infants, like those that are born severely premature – as early as 24 weeks – or born after being exposed to substances in utero. Some also have genetic, metabolic, or chronic disease, such as HIV, severe asthma, or diabetes. It's not uncommon for children at SPARK to be fed through gastric tubes or to need repeated medications and therapies throughout the day. Our goal is to make all of this normal for children, so that they can grow up with a sense of self-acceptance and competence related to recognizing and managing their symptoms."

In addition to the importance of SPARK's programs for the children they serve, this type of program has a significant impact on the overall health care system. Research has shown that children with complex medical conditions or who have suffered abuse or neglect early in their lives are more likely to experience health, educational, and psychological challenges later in life. Care for children and adolescents with these challenges comes at a huge cost to our health care system, both directly and indirectly. However, children who receive services such as the ones SPARK provides have been shown to improve behavioral and emotional competences, improve academic achievement – which leads to higher tax revenues and labor market success – and reduce their long-term social welfare use.

Most children at the SPARK Center are referred by pediatricians at BMC or community health centers. Others are referred by the Massachusetts Department of Children and Families (DCF) because of emotional and behavioral issues secondary to the trauma of parental separation, domestic violence, and neglect/abuse. Some of these children also experience multiple foster care placements. Many of the children referred by DCF also have health challenges and neurodevelopmental delays.

"An example of a case at SPARK is a boy who came to us at the age of four months, after spending two months in BMC's Neonatal Intensive Care Unit as a result of being born severely premature and at an extremely low birth weight, with repeated brain hemorrhages and respiratory challenges," says Vibbert. "He had trouble feeding well and growing. During the course of three years at SPARK, his parents gained confidence about how to meet his needs, his mother was able to return to work, his sleeping and eating routines stabilized, he got on track with cognitive development, he gained healthy social skills with his peers, and by the time he left us, he was able to graduate into kindergarten without the need for special services. It was a real victory."

SPARK operates as part of the Pediatrics department at BMC and is overseen by Vibbert and three other clinicians. The Center has 23 staff members, including pediatric RNs, a pediatrician, a child psychologist, early childhood and special needs educators, developmental specialists, a therapist, a program coordinator, and a nutrition coordinator. In addition, SPARK hosts early intervention specialists on site, and trains graduate interns in education, child life, psychology, and public health. The center also partners with many community organizations and academic institutions, such as Wheelock College, BU School of Education, the Boston Public Schools, the Massachusetts Department of Public Health, and the Center for Multicultural Training in Psychology at BU School of Medicine.

SPARK also has a variety of international partnerships that focus on caring for children with pediatric HIV and support and education for parents about early interaction with their babies, which encourages brain development. These partnerships include the testing of Universal Baby (UB), an innovative video and mobile intervention for creating and delivering culturally competent parent education and coaching. In this program, the UB team collaborates with local implementers to upload video footage of local parents' reciprocal interaction with their children, in their own culture and communities. The footage is edited to show strong moments of key "serve and return" interactions that encourage brain development and help parents recognize positive and helpful interactions. Parents are also taught the connection between these moments and neuronal connections forming in a baby's brain. The videos can be downloaded to mobile phones to help disseminate information to caregivers who otherwise might not have access to child development knowledge. This program is currently being tested in Boston, with the Cherokee Nation in Oklahoma, Peru, and Zambia.

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The Best Medicine for Trauma: Injury Prevention Center

Boston Medical Center is well-known for its trauma care but many are not aware that BMC is also a leader in research on trauma prevention. The hospital's Injury Prevention Center brings together research and injury prevention programs at BMC to ensure that patients are not only treated for injuries, but also gain the research-backed skills and knowledge to prevent future ones.

The Injury Prevention Center (IPC) was formed in 2010 through a collaboration between the Department of Emergency Medicine and the Division of Trauma Surgery. As a Level 1 trauma center, BMC was already required to have an injury prevention coordinator – the hospital's was Lisa Allee, LICSW, MSW, who still serves in this role – but Allee, Jonathan Olshaker, MD, Chief of the Department of Emergency Medicine, Peter Burke, MD, Chief of Trauma Services, and Jonathan Howland, PhD, MPH, MPA, now the Director of the IPC, saw the opportunity for a more comprehensive program. They integrated the existing injury prevention programs with research on injury prevention, and the IPC was born.

This integration of research and community prevention services is the core idea behind the IPC. Because BMC is the busiest trauma center in New England, researchers are given ample opportunity to look at the causes, treatment, and epidemiology of trauma. The IPC helps with this, organizing research projects, helping them apply for funding and recruit patients, and performing data analysis. And because BMC doctors see so many trauma cases, they were led to the question of how to prevent them from happening. The drive to answer this question comes through not only in research, but in the programs and services the IPC offers to patients to prevent subsequent injury.

"Having a department that provides services and allocates resources to the prevention of the problems they treat is crucial," says Howland. "We should simultaneously be engaged in care and prevention, but this is rare in injury prevention. BMC is one of just a few injury prevention centers at academic medical centers throughout the country, and has a unique approach on applying prevention tactics in a clinical setting, rather than just being research-oriented."

In addition to partnering with hospital programs such as the Violence Intervention Advocacy Program (VIAP), the IPC runs a number of programs to help prevent injuries. These programs are wide-ranging, from A Matter of Balance, an outreach program that helps prevent fear of falls in older adults, to a child passenger safety program, which was the first of its kind in Boston. The IPC also has a Community Violence Response Team, which provides free mental health counseling to 2000 patients and families a year who are affected by community violence.

The IPC also works closely with state and municipal agencies. For example, the IPC is the external evaluator for Massachusetts's injury prevention grant, funded by the Centers for Disease Control, under which the state has developed a five-year injury prevention strategic plan that focuses on safe sleep for infants, opioid overdose, older adult falls, sports concussions, and vehicular injuries. In addition, the IPC has worked with organizations such as the Women, Infants, and Children Nutrition Program (WIC) to evaluate outcomes of their programs and has consulted on fall prevention at Logan Airport.

The IPC also leads many in-hospital research projects. Howland, for example, is an expert in fall prevention for seniors and, with Kalpana Narayan, MD, Emergency Medicine, is conducting a study involving 100 seniors who come into the BMC ED with fall injuries. In addition, Emily Rothman, ScD, has been studying interpersonal violence prevention, notably in the area of teenage dating violence.

Traci Green, PhD, Deputy Director of the IPC, is the newest researcher at the IPC and is collaborating on a study with trauma service patients that examines opioid prescribing. She is also leading a study, in conjunction with Rhode Island Hospital and CVS Health, on best practices for providing naloxone in pharmacies. Green will also be working with a trauma team in Copenhagen to look at decision making for prescribing opioids.

"There's a lot we can all do every day," says Allee. "Most injuries are preventable. All of us in the medical field are in a unique position to take an active role in injury prevention. We are always available to educate providers/staff on how to work with patients and families on how to lower their risk."

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New Combined Program Prepares Residents for Population Health Practice

As a hospital, Boston Medical Center has long been a proponent of treating patients holistically and incorporating programs that address issues beyond traditional medicine, such as the Preventive Food Pantry, into care. And as the health care system continues its shift to reward care delivery that focuses on systemic and population health, BMC is well-positioned to move into the future. With the creation of a new combined residency program in primary care internal medicine and preventive medicine, BMC residents can now receive even stronger training in population health and learn how to incorporate it into clinical practice. This program is one of approximately five in the United States and the first one at a major academic medical center.

According to Jonathan Berz, MD, the director of the preventive medicine residency, internal medicine and preventive medicine are complimentary residencies, and many residents over the years have done them separately. With the new combined program, residents will be able to gain the benefits and knowledge of both programs, but in four years instead of the five it takes to go through the residencies separately. In addition, residents receive a Master of Science degree in health services or epidemiology at the end of the program. This dual training will provide residents with the skills and training to tackle pressing health problems, particularly in underserved populations.

A preventive medicine residency is an accredited residency that focuses on public health and population health training. It traditionally includes training in clinical preventive medicine, a practicum experience at a public health agency, research experience, and a master's degree at a school of public health.

Residents will spend the first year of the program focusing on internal medicine clinical training. The second year will begin by taking classes at the Boston University School of Public Health and residents will complete another year of internal medicine training. The third year will be split between public health classes and clinical training. During the fourth year of the program, residents will spend the majority of their time in preventive medicine, taking classes, working at a public health agency, and conducting research with a physician mentor. However, they will also continue to serve as the primary care physician of the patients in their continuity practice.

"In order to make improvements in the health of underserved populations, you need a bird's eye view," says Berz. "Hospitals around the country, including BMC, are shifting primary care toward population health, so providers can look at broader trends and attempt to make systemic changes that positively impact health. The residents in this program will be able to turn their career orientation early on toward public health and preventive medicine, which will inform their approach to solving major public health problems."

The first two residents in the combined program began in June, and the goal is to add two new residents per year.

"We are looking forward to seeing the first class through the program," says Berz. "It will be very exciting to see where people go in their careers after the residency."

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Clinicians and Computer Scientists Come Together to Predict Health Outcomes

Some things in life, like sunrises and sunsets, are predictable. Others, like traffic or the weather, are much harder to predict. Health outcomes tend to fall somewhere in the middle, but Bill Adams, MD, a Boston Medical Center pediatrician, and Yannis Paschalidis, PhD, a Boston University data scientist, are attempting to make more health outcomes predictable with an algorithm that utilizes electronic medical record data.

Their system, which is funded by a five-year grant from the National Science Foundation, utilizes anonymous data from BMC patients, which is stored in a database called I2B2. This data dates back to 2000 and includes diagnoses, procedures, admissions, length of stay, and basic demographic data. Adams had been using this data to study what works and what doesn't work in improving health outcomes for low-income patients and teamed up with Paschalidis and a team of graduate students to develop and test algorithms that can identify opportunities to alter health outcomes, some of which might be missed by researchers. Currently, the team is working on an algorithm to predict whether individual patients with a history of heart disease will be hospitalized within a year. In testing this algorithm, they have been able to predict approximately 80 percent of hospitalizations.

"The health care system is not very efficient," says Paschalidis. "We spend lots of money on diseases that can be prevented. With an algorithm that can predict re-hospitalization of high-risk patients, doctors can pay more attention to those patients, and potentially prevent re-hospitalization. Hospitalization is very expensive, but other health care costs are more modest, so predicting re-hospitalization and preventing it is better for both patients in terms of health and hospitals in terms of costs. In fact, the National Institutes of Health found that $30 billion is spent in the U.S. every year on preventable hospitalizations, so we have the opportunity to save huge amounts of money."

The goal is to have algorithms that will run in the background when providers see patients and alert providers when something in a patient's record suggests that he or she is at risk of a negative health outcome. It would prompt doctors to intervene during visits and case managers (if applicable) to intervene outside of doctor visits.

"While some risk factors, like smoking, are obvious to doctors, there are some, such as trends in laboratory data, that are harder to see," says Adams. "The challenge in medicine isn't to know that someone is high risk, but to know what type of risk they have and how to intervene. Our algorithm is a useful tool to help doctors intervene early before negative outcomes happen, instead of waiting for them to happen and then starting treatment."

The heart disease algorithm primarily uses outpatient data to make predictions, because most long-term health outcomes are treated in outpatient settings. The algorithm now utilizes information from BMC's new eMERGE electronic medical records system, allowing the researchers to share their work with people across the country who also use Epic electronic medical records. It will also allow researchers to better integrate inpatient and outpatient data.

The software built on the algorithm is not in use yet, but Adams and Paschalidis expect to finish testing by the end of the year and start running focus group pilots with BMC doctors next year. These groups will allow Adams and Paschalidis to refine the type of information their algorithm uncovers and how the data is presented to providers, to create an optimal tool. They also plan to expand the use of the algorithm to include diabetes patients and are in talks with BMC's Surgery department to predict re-hospitalization of patients who have undergone surgery – an important metric for Medicare quality measures. Eventually the goal is to create an algorithm that can provide recommendations for intervention, which will involve further partnerships between providers and computer scientists.

"This is a cutting-edge approach," says Adams. "There is general interest across the country in trying to use electronic data to predict health outcomes, but the BMC/BU team is special in that it combines the clinical expertise of the medical campus with expertise in engineering and computer science from BU. In addition, this type of project is not something generally undertaken in safety net hospitals, which makes our algorithm unique. Our goal is to make this data into something meaningful and useful for the direct care of our patients, and while we're not there yet, I believe we will be soon."

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