In health care, one of the biggest challenges facing patients and families is being able to access appropriate care, and that struggle is even more present in behavioral health. At Boston Medical Center (BMC), a health equity transformation looked to change that reality. In this conversation, three experts from BMC discuss the development of the Health Equity Accelerator, the partnerships needed to sustain the work, and how BMC was able to expand access to behavioral health services to historically underserved communities.

Tom Haederle

Welcome to Advancing Health. Coming up in today's episode, a conversation with Boston Medical Center about the launch of its Health Equity Accelerator Program and the difference it's making to expand access to behavioral health services to historically underserved communities. Our host is Rebecca Chickey, senior director of behavioral health services with AHA.

Rebecca Chickey

It is my honor today to be joined by three speakers from Boston Medical Center Health System. BMC Health System is a Foster McGaw Award winner. Their equity accelerator program has improved access to behavioral health services for historically marginalized and underserved communities. And so today, the three speakers that I am so lucky to be here with are Dr. Thea James, Trina Martin Cherry, and Dr. Christine Crawford.

Rebecca Chickey

So first I'm going to kick it over to Dr. James, VP of mission and associate CMO and the co-executive director of Health Equity Accelerator Program. So, Dr. James, can you lay a little bit of foundation for this?

Thea James, M.D.

Thea James, M.D.

And also three quarters of our patients are government insured. And so that just sets a picture only to state that there are many sort of structural barriers and systems that they face that often make it impossible for them to prioritize health. You know, they're making rational decisions because they're prioritizing survival, I would say. But, you know we continue with prioritizing clinical excellence and innovation and that type thing.

Thea James, M.D.

Thea James, M.D.

And we looked at the outcomes data for Boston. And what the leaders said is that we have been doing this work for decades, and it has had no impact on the outcomes data. It's highly predictable who's going to do what. So, we looked inside our house, across the entire enterprise, looking in operations, looking at clinical inpatient, outpatient research, education, human resources, even things like public safety.

Thea James, M.D.

And of course, we found things. What they did was to bring together about 80 leaders and also to divide us up into equal groups that cover those areas I spoke about, including the types of things that impact beyond health, things like economic mobility, which is a clearly root cause for why people are not able to prioritize their health.

Thea James, M.D.

And so each workgroup was led by an executive. And, there was a great deal of accountability put into it. There were dashboards. We had to report out every month. And I had a two-hour roundtable. It was quite intense. And we identified the clinical areas where there were highest rates of disparities and also some other areas.

Thea James, M.D.

And we were charged with closing gaps over the next 12 to 24 months. And we had to identify which gaps we were going to work on. One of the things we wanted to do was to sort of challenge conventional wisdom in the ways in which people actually go about this work.

Rebecca Chickey

Dr. James, thank you. You just described why you named to this program, the Health Equity Accelerator. You didn't want to just identify where the disparities were, but to accelerate the implementation of closing the gap of addressing and reducing those health disparities. So thank you for bringing that message home. I also heard you say, I think, that often when people get into this work, they have a need or a tendency to boil the ocean.

Rebecca Chickey

There are so many disparities that we can address. But yet you went through a process of identifying some key specific health disparities and populations that needed those gaps closed, and do so with an operational approach compared to a research approach. Now, I'm sure there's a lot of research that went on because I've seen some of the data that's come out of the work that you have. But you rolled up your sleeves and were pragmatic.

Rebecca Chickey

Was there anything I just said that was incorrect? Keep me, keep me honest here at the end!

Thea James, M.D.

No. It's correct. That's something I think important that I left out is: two very different approaches that have made this become such a proof of concept. It's what has enabled us to -we think - it has enabled us to have dramatic gap closures and in record time, I would say, is that, number one, when we look at data, we interpret it back to the root cause.

Thea James, M.D.

And that was the work we did in decision to incision when the ObGyn department created a model or an algorithm for addressing unplanned, urgent C-sections. So one is interrogating data back to the root cause, not being afraid to discover what you discover. And the second half of that is using the subjects of the data to interpret it, to tell you what it means, and partner with them to create solutions.

Thea James, M.D.

So usually when we look at data, you know, we sit down together and we come up with what these data mean. Even when people are writing papers about disparities or whatever, they sort of write conclusions based upon what they think the data mean. But not everyone has the lived experience of the subjects of the data. The data subjects -

Thea James, M.D.

we work with them to add context to what the quantitative data means and also again, partnering with us to create solutions.

Rebecca Chickey

Thank you, Dr. James. And that's a really nice segue to our next speaker here today, Petrina - or Trina, as she prefers to be called - Martin Cherry, who's the vice president of community engagement and external affairs at BMCHS. I'm going to turn to you, Trina, to say, can you speak a little bit to where behavioral health and this work fits into the overall mission for BMHS, but also, as Dr. James was just saying, the subjects of the data, that lived experience is so important in really understanding how to make a bigger impact and, unless I'm mistaken, all of the subjects in there lived in your communities.

Rebecca Chickey

And so the value and the importance of looking at the social determinants of health having an impact on the community health as a whole. I turn to you, Trina, to share some of that journey with us.

Petrina Martin Cherry

Hi, Rebecca. Thanks again for having us. And, thank you for your question. And I think to answer the base of that is that we don't see the community as subjects. Like, they are a community with a lived experience that we could not do the work without having them, and what their daily experience is at the table to really help us understand that. At BMC we have an amazing history of having an incredible amount of trust with the communities we serve, because historically, they've seen us as being an institution that is there for them in a multiple amount of ways.

Petrina Martin Cherry

We often come out of our campus into communities, and we show up for them in a way that's real to them. We have authentic partnerships with community-based organizations, so we think it's really important to make sure that when we are like planning a program through our health equity accelerator - maternal/ health, behavioral health, whatever it is - making sure that we are working with community health centers, community based organizations, that we are using our community advisory boards to ask the questions about what we are doing, are we doing it right, where we need to flex, and when we hear back from them, we pivot.

Petrina Martin Cherry

We understand that you can't invite the community to the table and ask them for advice and guidance and when they give it to you, you don't move on it. And so that's one of the things that I really, really love about BMC. We take the advice of those with lived experience and pivot when necessary. In terms of the work of health equity accelerator and the work we're doing in behavioral health, I think that it is important that we have those relationships with anchor institutions in the city of Boston and in the Commonwealth.

Petrina Martin Cherry

So anchor institutions like community health centers, I mentioned those already, but also the Boys and Girls Clubs, the YMCAs, Boston Public Schools. We've been there. We partnered with them and other things so that when we, you know, wanted and needed to set up critical services to make critical services and behavioral health available, there was trust there where it made them more willing to say yes and to partner with us.

Petrina Martin Cherry

One other really great example about us reaching out to community, getting their feedback and then actually stepping in and doing something about some of the issues that we heard: In Roxbury, which is an incredible city in Boston where the life expectancy is I think about a 23-year life expectancy gap from the south end of Boston to Roxbury, which is literally about two bus stops, and there's a 23-year life expectancy gap.

Petrina Martin Cherry

We spend a lot of time working in that community, talking to them, asking them what it is that they need, how we can, you know, close the gaps on some of these things. And one of the things that we heard back was that they wanted more access to healthy food. They wanted more availability for black businesses to thrive in that area.

Petrina Martin Cherry

And so Boston Medical Center invested well over $1 million in a black owned grocery store. And so this is one of the things that really helped us to win the Foster McGaw Award, our work with Nubian markets. The investment in that neighborhood with that particular business has been just incredible. So not only is it a beautiful grocery store with amazing fresh fruits and vegetables, it's also a halal butchery.

Petrina Martin Cherry

It's also an incredible cafe where folks can get foods that are delicious but also healthy, prepared by a chef who has been featured in Bon Appetit. And it goes to show that no matter what zip code you you're in, you deserve the best food. You that deserve the best health care. You deserve the best opportunities to thrive.

Rebecca Chickey

Trina, that was fantastic. We got into health care to help other people, right? And if we're not listening to those people and what their needs truly are, we're missing opportunities to help. Dr. Crawford, I'm going to kick it over to you now to, share some of the experiences and inspire others to go on this journey.

Christine Crawford, M.D.

Yeah. What we know to be true is that the patient to receives their care at Boston Medical Center, whether it's primary care, ObGyn care, whatever type of care it is - at the heart of their ability to take care of their physical health,

Christine Crawford, M.D.

we also have to address their mental health. Because we have fantastic providers: nurses, nurse practitioners, physicians here who are working tirelessly to improve the physical well-being of our patients. But what we know as a hospital, what we know as a system, is that we really have to pay special attention to the mental health needs of this patient population while being mindful of the unique mental health needs of this specific population, just given their vulnerabilities and historically, what it is that they've been through, and the fact that access to mental health supports not only in the city of Boston, but also across the country is quite limited.

Christine Crawford, M.D.

And so I've always appreciated how invested in this hospital, this hospital system has been in finding ways to improve access to mental health services for this highly vulnerable population. Not only are we invested in mental health supports within the physical walls of the hospital, and thinking about our psychiatric hospital that we opened a couple of years ago, that's providing inpatient level of care for our sickest individuals who are living with psychiatric symptoms,

Christine Crawford, M.D.

but we're also looking at ways in which we can increase access while out in the community. And so having the opportunity to work in some of our community health centers, such as Codman Square, where they see a large number of primary care patients and the overwhelming percentage of those patients are also living with mental health conditions. And so a number of our psychiatrists, not only do they see patients here at Boston Medical Center, but they're also providing care out in the community within these community health centers. Which is fantastic because there are so many barriers that make it challenging for people in the community to come over to our hospital, even though we're not

Christine Crawford, M.D.

that far away. But it's a very complicated city to navigate, just given the way in which the city was designed because of historical practices way back when that made it such that public transportation posed significant barriers for people to come into the city, into our hospital to get care. The other wonderful thing is that there have been a number of schools, not only in the city of Boston, but across the country, that I've reaped the benefits of having mental health clinicians and specific mental health support within the schools.

Christine Crawford, M.D.

Since we know that kids are spending a large part of their lives inside of schools, it's a really important place to provide psychiatric care, to provide mental health care so that we can meet the kids where they're at. So here at Boston Medical Center, we have partnered with the Boston Public Health Commission, which has a number of mental health clinicians who work in health centers that are embedded in a number of middle schools and high schools all throughout the city of Boston.

Christine Crawford, M.D.

What's truly unique about these social workers and these licensed mental health clinicians is that they are hired to be in the schools to only provide therapy. Other social workers who are hired by the Boston Public Schools are hired to do therapy, to provide counseling, but they're also doing cafeteria duty. They're also doing school bus duty. They're doing the field trips.

Christine Crawford, M.D.

They're doing a whole bunch of other things and filling in all these different gaps that we see in a lot of the schools, because it's been so hard to retain people in the school buildings. But these clinicians, all they do each and every day is provide therapy. One hour therapy to students inside of the school. What parents need to do at the beginning of the school year, they sign a permission form that grants the kid access to all of the services within the health center.

Christine Crawford, M.D.

Some of those services include mental health services. So what's absolutely beautiful about this program is that if a student happens to develop some mental health needs, they can go straight down to the health center. Pair up with one of the clinicians and not have to talk to their parents about it. Get special permission. It's fantastic. The other thing, too, is that these clinicians document all of their notes, all of their encounters in our medical record system at Boston Medical Center.

Christine Crawford, M.D.

So we have the capacity to communicate, these clinicians, to communicate with their primary care providers at Boston Medical Center, as well as other providers. So everyone is looped in to all of the needs of this one individual child who spends the majority of their time in school. And being a psychiatrist, I meet with these clinicians monthly to supervise them to discuss challenging cases, and to identify if there are any potential students who would benefit from medication management and as an easy referral to my clinic.

Christine Crawford, M.D.

And so the fact that we are investing the resources to connect these licensed mental health clinicians, these social workers who are providing therapy in school such that they are documenting in our medical system, closing the loop, making it such that we're filling this need is absolutely wonderful. And not a lot of health systems are thinking outside of the box in that sort of way,

Christine Crawford, M.D.

and BMC is.

Rebecca Chickey

Wow, that is phenomenal. The ability to have those notes integrated into the EHR so that it goes to their primary care physician. The fact that the licensed mental health clinicians working in the school are able to focus on that one purpose, then the fact that that distraction doesn't happen in this case is just so phenomenal.

Rebecca Chickey

Thank you so much for sharing your time and expertise here today, for being innovators. You've inspired us and inspired the listeners. I'm going to challenge all of the listeners to help get your dream in terms of accessing mental health services. Regardless, there should be no wrong door. And thank you so much for the work that you do.

Rebecca Chickey

Keep up the great work. You brought joy in my heart and I hope others today as well.

Tom Haederle

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