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Service Delivery Innovation Profile

Physician “Prescriptions” Written During Medical Visit and “Filled” by Onsite Volunteers Connect Low-Income Families to Vital Community Resources


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Snapshot

Summary

As part of a program known as Health Leads (formerly Project HEALTH), physicians in inner-city care settings write “prescriptions” for basic community resources such as food stamps, utilities assistance, job training, educational assistance, and housing vouchers when they identify these needs in low-income families during medical visits. Families take these prescriptions to a help desk located in the clinic waiting room, where college student volunteers “fill” them by making referrals to needed resources. Volunteers follow up on a weekly basis with the families to ensure that they have accessed these services. Health Leads has successfully connected most clients to needed resources and has generated high levels of client satisfaction. Anecdotal reports suggest that it has had a meaningful impact on the health and well-being of low-income families, with many reporting that the program stabilized their lives (see the Story section for examples of two families helped by the program).

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation statistics on the percentage and number of clients connected to needed resources within 90 days, client satisfaction among those connected to resources, and anecdotal reports from clients on the program's impact on their health and well-being.
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Developing Organizations

Health Leads
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Date First Implemented

1996
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Patient Population

Vulnerable Populations > Impoverished; Urban populationsend pp

Problem Addressed

Traditional medical care does not address the basic resource needs of low-income families, which can have a negative impact on health outcomes and costs. Physicians typically lack the time and infrastructure necessary to be able to effectively address such resource needs during medical visits.
  • Significant impact on health: Basic resource needs—such as those related to food, housing, and utilities—directly affect health outcomes and costs.1 For example, a physician may counsel a patient to lose weight and exercise more, but that patient may not be able to afford nutritious food or have a place to exercise safely in his or her neighborhood.2 Research has confirmed the link between limited resources and health outcomes; for example, children who lack access to healthy foods3 and children whose families cannot pay their utility bills4 are 30 percent more likely to be hospitalized.
  • Physician failure to inquire about and assist with resource needs: A survey conducted at Johns Hopkins Medical Center found that 98 percent of families expected their pediatricians to ask them about resource needs that could affect their health (such as food, housing, and utilities), but only 11 percent of physicians did so, due primarily to time constraints as well as apprehension at asking about resource needs in the absence of a clinical mechanism to effectively identify solutions to those needs.5 By embracing a broader definition of “health care” for low-income Americans—to include support related to food, housing, and basic resources—physicians who treat inner-city residents may increase the likelihood that these individuals achieve healthier outcomes.

What They Did

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Description of the Innovative Activity

As part of a program known as Health Leads, physicians in inner-city care settings write “prescriptions” for basic community resources such as food, utilities assistance, and housing vouchers when providing medical care to low-income families. Families take these prescriptions to a help desk located in the clinic waiting room, where college student volunteers “fill” the prescriptions by making referrals to needed resources. Volunteers follow up on a weekly basis with the families to ensure that they have accessed these services. Key elements of the program include the following:
  • Screening tool to identify resource needs: When checking in at the clinic, families receive a screening tool with questions related to resource needs. Sample questions include, “At the end of the month, are you running short of food?” and “Are you interested in information about job training programs?” The tool, which is often administered as part of standard patient paperwork, travels with the family to their visit with the physician. In some Health Leads sites, the nurse or patient technician who completes the standard intake process (e.g., measuring height, weight, and vital signs) administers the screen.
  • Discussion of needs with physician: In the examination room, the physician reviews the patient's medical information along with his or her answers to the questions on the tool, and then initiates a conversation about resource needs as a routine part of the visit.
  • "Prescriptions" for needed resources: The physician writes a “prescription” for needed resources using a special Health Leads prescription pad. Prescription pads allow the physician to check one or more of the following resource needs: food assistance, housing needs, income supports, fuel/utilities assistance, health insurance, job search/training, adult education, childcare, clothing, and after-school programs. More than three-fourths of clients present with more than one need, and more than one-third present with three or more needs.
  • Further assessment by volunteer: After the examination ends, the physician walks the family to the Health Leads help desk in the waiting room, where a college student volunteer performs a more detailed intake process to further assess the needs listed on the prescription and to identify any additional needs the physician may have missed. The volunteer also creates a record of the family (including contact information) in a client database.
  • Connection to needed resources: The volunteer “fills” the prescription by referring the family to specific community resources. The volunteer identifies available resources by searching a comprehensive database that lists a wide variety of community services/agencies, along with characteristics about them, such as responsiveness, length of waiting list for services, etc. Volunteers regularly maintain and update the database. The volunteer prints information about selected resources to hand to the client, and documents these referrals in the database. The typical client receives assistance in accessing three different community resources.
  • Follow up to ensure resource provision: Volunteers follow up with families each week until they determine that the family has obtained resources to meet each of their needs. When volunteers identify a barrier to obtaining resources, they notify program coordinators (experienced volunteers who manage several new volunteers) or program managers (paid Health Leads staff, typically social workers or former volunteers with extensive case management experience) who intervene with community agencies to facilitate the provision of needed resources.
  • Support from other clinic-affiliated professionals: Health Leads program managers work closely with social workers, lawyers, mental health counselors, and other professionals in the clinic to determine which professionals should optimally manage each client’s particular nonmedical needs. For example, the program manager may help a client meet basic food needs, while other professionals may become involved when more complex and/or higher-risk needs surface.

Context of the Innovation

While working in the housing unit at Greater Boston Legal Services, Rebecca Onie, then a freshman at Harvard College, saw firsthand the link between poverty and poor health. After reading an article in the Boston Globe about Dr. Barry Zuckermann, Chief of Pediatrics at Boston Medical Center, Rebecca spent 6 months at the hospital speaking with doctors and patients. Upon hearing stories of the challenges that physicians and families were facing, she identified the need to connect impoverished individuals to resources that could have a positive impact on their health and life. As a result, Ms. Onie founded Project HEALTH (now called Health Leads) in 1996. The program, which is headquartered in Boston, currently has 48 full-time staff and 750 student volunteers serving almost 6,000 families in six cities (Baltimore, Boston, Chicago, New York, Providence, and the District of Columbia). The program's 20 Health Leads help desks are located in various settings, including inner-city pediatric clinics, obstetrics/gynecology wards, pediatric emergency departments, and Federally Qualified Health Centers.

Did It Work?

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Results

In 2009, nearly 60 percent of Health Leads' clients actually obtained at least one resource they needed (i.e., received food, got their heat turned back on, found a job) within 90 days of receiving services. Anecdotal reports suggest that the program has had a meaningful impact on the health and well-being of clients, with many reporting that the program stabilized their lives (see the Story section for examples of two families helped by the program). Health Leads leadership is currently developing a comprehensive strategy to evaluate the program's impact on health outcomes and utilization.

  • Most clients connected to needed resources: Across 20 sites, 59 percent of Health Leads clients have received needed resources within 90 days of speaking with the volunteer. A study conducted over 5 months in 2009 at Boston Medical Center found that the program had connected clients to the following:
    • Housing assistance: 205 families secured housing, including in Section 8 and market rate units and in shelters.
    • Child-related services: 154 clients obtained slots in childcare, after-school, and Head Start programs.
    • Food support: 135 clients accessed food stamps, food pantries, dollar-a-bag programs, or farmers' markets.
  • High client satisfaction: A retrospective longitudinal study followed Baltimore's Harriet Lane Clinic clients from their initial visit through the time they received resources; the study found that more than 90 percent of those receiving resources were somewhat or very satisfied with them.
  • Improved health and well-being: Anecdotal reports suggest that Health Leads often has a meaningful, positive impact on the health and well-being of clients, with many families reporting that the program has stabilized and/or improved their lives. (See the Story section for examples of two such families.)

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation statistics on the percentage and number of clients connected to needed resources within 90 days, client satisfaction among those connected to resources, and anecdotal reports from clients on the program's impact on their health and well-being.

How They Did It

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Planning and Development Process

Key elements of the site-specific planning and development process include the following:
  • Site selection: To date, Health Leads sites have developed organically based on interest; in the future, formal criteria will guide site selection. Although these criteria are currently under development, attractive sites will typically be those that have strong working relationships between the institution, local university, and social service agencies; local funding support; a large Medicaid population; and ample availability of student volunteers.
  • Identification of clinic champion: Each site identifies a Health Leads champion who supports program adoption and serves as a liaison for implementation. The champion may be a medical director, senior attending physician, or hospital administrator.
  • Interface with professionals: Health Leads national office staff meet with social workers, lawyers, mental health professionals, and other professionals working at the site to identify common client needs and design a productive system for professional interaction.
  • Volunteer training: Volunteers receive training on how to work with families, search and update the community resource database, and conduct followup calls. Each volunteer undergoes a minimum of 15 hours of training over approximately 3 days. Key components include an orientation to Health Leads, standard volunteer orientation (e.g., related to cultural competency, privacy and security regulations, safety), and education about community resources. The Health Leads national office provides training-related materials, although certain components (such as the resource training) may be customized by sites to the local environment and care setting.
  • Physician training: Program managers, program coordinators, and volunteers conduct training sessions with physicians/residents. This program includes a description of how the help desk works and how to refer patients to it by writing prescriptions, education on the wide variety of resource needs that affect the health of low-income families, and training on how to converse with families about these needs.

Resources Used and Skills Needed

  • Staffing: Health Leads suggests that one paid program manager should provide oversight to 30 volunteers, with each volunteer serving up to 16 clients annually. In other words, one paid program manager could oversee the services provided to 480 clients each year.
  • Costs: The cost of running a Health Leads help desk depends on the size of the practice and the necessary level of staffing. Using the staffing ratio cited above, the cost of staffing one desk ranges from $80,000 to $150,000 annually. For the nationwide program as a whole, Health Leads leaders expect to spend approximately $11 million on ongoing development and expansion between 2011 and 2015.
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Funding Sources

Robert Wood Johnson Foundation; NewProfit, Inc.; Samberg Family Foundation
Funding consists of philanthropy and in-kind donations from Health Leads sites. Currently, four sites contribute to or cover the costs of their Health Leads help desk. Major philanthropic donors have included the Robert Wood Johnson Foundation, which provided a $2 million capacity-building grant in 2009, and New Profit Inc., a venture philanthropy firm in Cambridge.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Include all relevant individuals: The most successful sites include representatives from the hospital, local social services agencies, and the local university in all stages of program implementation.
  • Identify clinic champion: The champion can help program staff navigate relationships with the hospital, university, and site staff (e.g., social workers, nurses), thus ensuring their understanding of and support for the program.
  • Use tools to facilitate physician adoption: The previsit screening tool makes evaluation of resource needs a “standard operating procedure” within the clinic and serves as a reminder to the physician to initiate a conversation with the family. Without such a tool, the physician may neglect to discuss resource needs and instead focus only on medical needs, especially given the time constraints of the typical visit. Prescription pads also make it easy for physicians to communicate resource needs to help desk volunteers.

Sustaining This Innovation

  • Identify local funding sources: Program sustainability hinges on the ability to identify local funding (either from the institution itself, the local health department, or philanthropic organizations). Going forward, Health Leads leaders hope to demonstrate that the model is cost effective and generates positive health outcomes, thus making it easier for implementing sites and/or third-party payers to justify providing ongoing funding to ensure sustainability.
  • Select sites with many available volunteers: The program can be sustained more easily in sites with access to many college students interested in serving as volunteers.
  • Encourage sharing of best practices: Sites should be encouraged to share effective strategies for recruiting and training volunteers, customizing training materials, orienting physicians, and other aspects of the program.

Spreading This Innovation

Project HEALTH (now called Health Leads) originated in Boston in 1996 and has since spread to 20 sites throughout 5 additional cities, including Baltimore, Chicago, New York, Providence, and the District of Columbia. Program headquarters remain in Boston, and health centers in the other cities follow the original program model of writing prescriptions to connect patients to basic resources in their local communities. Additional information on program growth can be found in the Context of the Innovation section and the Planning and Development section.

More Information

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Contact the Innovator

Sonia Sarkar
Chief of Staff to the CEO
Health Leads
Boston Medical Center
88 E. Newton St., Vose 522
Boston, MA 02118
(617) 863-0766
E-mail: ssarkar@healthleadsusa.org

Innovator Disclosures

Ms. Sarkar has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Health Leads Web site: http://www.healthleadsusa.org.

The 2010 O Power List. O, the Oprah Magazine. September 14, 2010.

Project HEALTH Receives Grant from RWJF and Recognition from First Lady Michelle Obama. Robert Wood Johnson Foundation. May 19, 2009. Available at: http://www.rwjf.org/pr/product.jsp?id=42848.

Footnotes

1 Project HEALTH: Mobilizing Our Nation’s College Students to Change Health Delivery. Project HEALTH.
2 The 2010 O Power List. O, the Oprah Magazine. September 14, 2010.
3 Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134(6):1432-8. [PubMed]
4 Frank DA, Neault NB, Skalicky A, et al. Heat or eat: the Low Income Home Energy Assistance Program and nutritional and health risks among children less than 3 years of age. Pediatrics. 2006;118(5):e1293-302. [PubMed]
5 Garg A, Butz AM, Dworkin PH, et al. Screening for basic social needs at a medical home for low-income children. Clin Pediatr (Phila). 2009;48(1):32-6. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 16, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Back Story
Each day, Health Leads volunteers help families whose health and treatment are affected by multiple, sometimes seemingly insurmountable resource needs. What follows are examples of how volunteers helped two families significantly improve their circumstances.

The first story involves the Jacksons, who came to the Harriet Lane Clinic at...

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