Improving health in Boston, one patient at a time

By Kanupriya Tewari

	A Diabetes patient receives a visit from her community health worker at her home in Boston.

Partners In Health’s US-based PACT project (Prevention and Access to Care and Treatment) is expanding to serve thousands of Boston’s sickest and poorest residents.

In January, PACT began partnering with Network Health (a MassHealth insurance provider that supports low-income Massachusetts residents) and the nonprofit Commonwealth Care Alliance to provide specialized, individualized care to patients with particularly complex chronic needs. These patients are living with two or more chronic diseases, such as HIV/AIDS, diabetes, hypertension, heart disease, addiction, and mental illness. Using community health workers (CHWs), the goal is to improve health outcomes of the patients, while reducing the cost of care.

Since 1995, PACT has employed CHWs to provide home-based services to Boston’s most marginalized HIV/AIDS patients. Because CHWs come from the same communities and share many of the same experiences as their patients, they are uniquely qualified to provide effective treatment and support. They deliver individualized care within the real-world contexts, cultures, and belief systems of their patients. With training and support from PACT, CHWs aim to empower, not simply assist, their clients.

The new collaboration, known as Network Health Alliance (NHA) utilizes the approach PACT has used for HIV/AIDS patients to provide services to patients with other chronic conditions. NHA features a unique home-based and over-the-phone care management program that deploys teams of nurse practitioners, social workers, resource specialists, and CHWs to complement clinic-based provider care. The NHA teams educate and counsel individuals to avoid preventable emergencies, hospitalizations, and help them achieve better health and quality of life.

“We are hoping that our program evaluation will show that emergencies and hospitalization numbers have decreased and health outcomes improved because more patients are adhering to their treatment and going to their appointments,” says Dr. Heidi Behforouz, PACT’s founder and executive director.

The NHA teams are already working with about 400 children and 1,700 adults in the Cambridge Health Alliance system, a collaborative group of hospitals and health care centers in Cambridge, MA. Next up, the NHA plans to begin serving about 400 high-risk patients receiving care through the South Cove Health Centers, in Boston and Quincy.

This project is the first time PACT has served child patients. Of the 400 initially enrolled children, staff determined that approximately 60-65 percent could be aided by minimal but meaningful interventions. For example, often a child and his or her family just need someone to call and remind them to schedule a doctor’s appointment, or to renew a medication. The remaining 35-40 percent of children require more direct care. Many of these children live in challenging home environments, have significant mental and behavioral health needs, or struggle with asthma and obesity. An outreach team – a nurse, two community health workers, and one mental and behavioral health expert – will work together to address the specific needs of each of these children.

“The key to the model is the constant monitoring of patients to determine what kind of intervention they need most at what time,” emphasizes Dr. Behforouz.

While the outreach team monitors the patient’s and family’s health, CHWs also educate families on topics like parenting children with behavioral challenges; buying and preparing nutritious foods; and using HEPA-filter vacuum cleaners to minimize dust and mold in the home. To make this initiative a success, the NHA teams will work closely with each child’s support system to ensure that patients with complicated issues, like mental and behavioral health disorders, are provided adequate support at home and at school. 

PACT and its collaborators believe that better care coordination will improve health outcomes for adults and children, while and bringing new cost-saving efficiencies to Massachusetts’s public health care system.