Start Your Visit Now

Melanie Cole (Host):  Boston Medical Center just launched a resource directory designed to help connect individuals to the social services that they may need. My guests today are Tracey Fredricks, she’s the manager of Strategy Implementation, Lily Sonis, she’s the medical case manager for the Immigrant and Refugee Health Program and Erin Nahrgang, she’s the manager for ACO Transformation and Care Management all at Boston Medical Center. Ladies, welcome to the show. I’m so glad you could join us today. So, Erin, I’d like to start with you. BMC has a goal to make Boston the healthiest urban population in the world. Tell us what that means. What does that even entail?

Erin Nahrgang, RN (Guest): Traditionally when you think about healthcare delivery in a hospital setting such as Boston Medical Center, you think about specialist’s appointments and primary care appointments and surgery and medicine and what Boston Medical Center has a history of doing and is now turning a focus toward is looking at the total health of populations in urban centers. And what that means is that there are unique needs of people living in urban centers that impacts their healthcare which may not be traditionally addressed by a healthcare setting. Things like food security, secure and safe housing, access to support in other to have a healthy family, electricity, being able to pay your bills. There are a lot of factors that most of us take for granted that we don’t consider part of healthcare, but which have a very meaningful impact on how people utilize the healthcare system. So, what Boston Medical Center is doing is recognizing that if we can address those needs, we can increase the health of the entire population and bring everybody to a level where they can address – they can access care and address their own health and wellbeing on their terms because they have their needs met from a social standpoint.

Melanie:  That is amazing, and I have done so many shows for Boston Medical Center and I have recognized the fact that they do these amazing reach outs to the community that don’t necessarily involve hospital setting activities. So, Lily, when I ask you, what does this mean when I hear that you are treating all health and socioeconomic complexities existing among your patients and their families. What does that mean?

Lily Sonis, LCSW, MPH (Guest):  Well so, I work in the immigrant and refugee health program and our patients have really complex social, legal, and other needs. A lot of our patients may be coming from having experienced a lot of trauma. Many of them may be undergoing current legal proceedings. They face language and cultural barriers. They may not be eligible for public benefits or other programs that one would typically think of. So, we have been trying to sort of address all of those needs within our clinic. Not only do we have the primary care, but we also help to connect patients to community and legal resources. Trying to help patients to access housing, food, job training, ESOL program, and really the range of things that allow a person to meet all their needs.

Melanie:  It is truly the definition of comprehensive and multidisciplinary. So, now Tracey, I hear about this Thrive directory at BMC. How will this platform make it easier for residents of Massachusetts to get the help they need and please describe the two versions of the directory that you have got going now. What is it?

Tracey Fredricks, MPH (Guest):  Sure. So, Thrive directory is an online platform which houses a comprehensive list of state programs – state programs and resources. There are also national programs on the platform that serve our Massachusetts residents. So, what it is is it provides resources across the state and nationally that address the social needs of our patient population. Right now, what’s happening is that our patients and even our staff are spending a lot of time Googling resources, and or they have a lot of our staff have outdated binders. They have Excel spreadsheet. They had emails that they are sending around to each other that house information about local resources that can address social needs and what we found is that as I stated, that information becomes outdated really quickly and sometimes it’s updated on Google, a lot of the times it’s not. Sometimes staff has the chance to update the information, a lot of the times, they don’t. And then patients rarely go through the hassle of digging deep to figure out if this organization is still up and running or not, if the phone number is correct. It’s just a lot of things in the process of just making sure that the resources that we want to connect with, we have the right information to do so. So, the directory has two interfaces. We have one that will be patient facing. So, that’s anyone within the community who is interested in finding resources to address their needs can go onto the platform, figure out what they would like to address and then find resources based on either their zip code or the city that they are located in. With the staff facing site, it gives us the ability – it gives our staff the ability to speak with one another and share resources information to one another on the electronic platform. I actually had a meeting today and I was asking staff how do they share information with each other. And they were telling they had group text messages asking about resources and trying to figure out how to update it or they have email threads where they share their go to resources and what we found is that staff worked consistently recreating the wheel. And we don’t want that time – we don’t want them spending their time on that. So, what the platform will do is it will provide a one-stop shop for resources throughout the state that meet our patient’s needs and will have the vendor, known as ___ they’ll be responsible for making sure that the information on the platform is up to date. So, that task is no longer on the shoulders of the patients and our staff.

Melanie:  Now Tracey, so one of the versions is for the staff and the patients. Are these user-friendly, it’s a website, right? Tell us how it works.

Tracey:  Well it is so user-friendly. You go onto the website, the first thing you see is for you to put in either your city or your zip code to help them narrow where they want to search for resources, where the platform wants to search for resources. Once you put in your city or your zip code, there are then about ten categories across the top of the screen that cover all of the needs that one may have. That includes food, that includes health, that includes housing, that includes legal. There are about six or so more categories across the screen. You can search two ways. You can either search by the categories, each category has a subcategory. So, for food, if you hover over food, emergency food, food pantries, It’s Food Program or you can search by key words. If you know exactly what you are looking for, you just type it in and then the search results pull right up.

Melanie:  How can people find it?

Tracey:  We have a – for the staff-facing site, it is available on our internet page at There is a button that says Thrive directory. And for the patient-facing site, they can go to

Melanie: for the patient-facing site. How interesting is that. Now Lily, how can this help with shelter for example and Tracey mentioned food and food insecurity. So, if somebody is looking for this, tell us how it can help with that.

Lily:  Yeah, so I think a lot of the patients that I work with, they often are really unfamiliar with even that there are food pantries or that there are resources for people because they are coming from other countries that don’t have those sorts of safety net programs. So, just giving people a website where they can look up that information and learn that there are things like that available I think can be beneficial. I have kind of like my go-to resources that I use a lot that I know work and that I send people to regularly so, I have my little sort of area favorites and often a lot of our patients have similar needs, so I know I need to get them the food resource, I need to get them housing resource etc. and people seem to find that pretty easy to absorb the information that way.

Melanie:  Lily, I’m sticking with you for a second since you are involved in immigrant and refugee health program. Are there resources for mental health, stress, things that are going on today could cause an extreme amount of stress for immigrants and refugees and then even child care assistance and things like that so that they can look for work and figure out what they are doing?

Lily:  Yeah, there are actually a lot of mental health resources on the directory which is really nice because we have mental health services here at Boston Medical Center but many patients because we are a safety-net hospital, travel from quite far away to get care here and so for some of them, coming to BMC from Lowell or Lawrence or even Wooster is not feasible but they can – we are able through the directory to find mental health resources in their communities which is really much more helpful. And childcare yeah, it’s a good resource for that as well. People who are coming to this country and coming with children of course are going to need those resources and the directory helps with that.

Tracey:  I’d like to add one thing. The platform has the ability to – for you to filter like have personal filters for you to filter the results so it could be a bit more targeted for the patient that you are working with or if you are the individual you will be able to target it for your needs and under certain categories, there is the option for you to filter by immigration and or refugee status so you can have more targeted resources for the patient or individual in need.

Erin:  The other thing that’s so great about this platform one new intervention for Boston Medical Center in reaching the community, is to send out mobile staff, so we have community health workers, nurses, pharmacists, some behavioral health specialists who are actually going into the community and meeting patients in their homes, in their shelters, places where they live and having this resource on a web based platform allows us to have all of this information at our fingertips when we are in the community with our patients. So, where previously, your whole world lives in your office and you are connecting to patients by phone, now we can sit with someone in their living room to discuss what their needs are and connect them to resources in the same moment to get them on the right track.

Tracey:  So, with this platform, you don’t need to have – you don’t need to be attached to a laptop, you don’t need to have your desktop, Excel spreadsheet. The minute you walk out of the hospital, you have all of the resources right at your fingertips.

Melanie:  So, I would like you all to do a little wrap up for me and Lily I will start with you. Please just tell us – tell the listeners what you would like them to know about these resources available.

Lily:  Yeah, so, I think treating health involves looking at so many different parts of what a person needs and what they – parts of their environment and so there are really easy ways to get patients connected to things that can improve their health like housing, food, mental health care, job training, and I think if people start to explore the directory, they’ll see that you can connect people even just with like a click of a button where you click connect and it sends the referral actually to the outside organization so, this can be a part of anyone’s workflow.

Melanie:  Erin, up to you, just what would you like everyone to know about using the website and about the Boston Medical Center’s ability to reach out into the community and help with things that you wouldn’t necessarily think a hospital would do.

Erin:  I think one of the great things about this directory is that it brings everybody to the playing field, whether it’s a patient researching resources for themselves or a community health worker helping and exploring on their behalf. Anyone who is a part of this network can help identify these resources for patients. And what that does for the patient, is it empowers them to find and access these resources and then remove that barrier so that they can address the things about their health that are important to them. So, it really gives the power and the ability to the patients and to the staff to address these concerns as they find them rather than waiting months for an appointment or ending up in the emergency department where the resources available to address really the social factors that are contributing to these health problems.

Melanie:  Tracey, here goes your last word. Because as you have described for us this Thrive directory, and you have explained it so well, give the website again where people can find out more about it and tell us what you’d like to know about the implementation of this directory.

Tracey:  I would like to start by saying that this directory was built with our staff members. This wasn’t something that came from the top down. We have had our – we call them our high-touch teams so social work, care coordinators, patient navigators, community health workers etc. We have had them involved in the process from start to finish. This directory was built for you all, for our staff. It was built with them in mind. It was built for them and I’m just really thrilled to even be a part of the process especially now that it’s live. It’s a very, very exciting time because we are introducing it to them at least in the last two weeks or so, introducing basically the product that they helped us create to them and they are so excited. Again, if you want to peruse the site you can visit if you are a patient at and if you are a staff member the platform is

Melanie:  Thank you ladies so much and thank you for all the wonderful work that you are doing for the community in all of this outreach. Thank you again for joining us. This is Boston Med Talks with Boston Medical Center. For more information, you can go to that’s This is Melanie Cole. Thanks so much for listening.