Rebecca Onie is building a movement to break the link between poverty and poor health by mobilizing undergraduate volunteers to provide sustained public health interventions in partnership with urban medical centers, universities, and community organizations.
The New Idea
Rebecca understands that for children and families in poverty, even the highest quality traditional medical care is not enough to improve health outcomes—a prescription for antibiotics does little for a child who goes to bed hungry. Her idea is to make health clinics the gateway to the community resources low-income families need to get healthy and stay healthy.
In 1996, while a sophomore in college, Rebecca founded Project HEALTH as a student-led initiative to enable pediatricians to expand their diagnosis and prescriptions to include the unmet resource needs that affect the health of children living in poverty. Today, Project HEALTH has moved from a student project to an independent citizen sector organization with over 600 student volunteers staffing Family Help Desks in clinics of urban medical centers. Trained volunteers help families fill a doctor’s “prescriptions” for basic needs such as food, housing and childcare. Physicians and Family Help Desk volunteers team up with vulnerable families to help them stabilize and improve their lives, achieve upward mobility through education and job training, and change the outlook for the health and well-being of their children.
Rebecca wants to do for health care what Teach for America has done for public education. She envisions Project HEALTH playing a catalytic role in causing domestic health care to experience the same influx of social entrepreneurs that education has. By training college students to serve as liaisons between patients, doctors, and community resources, Rebecca is building a movement of future leaders with the conviction, knowledge, and experience to break through the barriers between poverty and health by integrating social services into patient care. She aims to change the health care system from within to ensure that patients’ resource needs are routinely and systematically addressed as a standard component of patient care.
The well-documented link between poverty and health is known and accepted in the developing world but has not been factored into the design of the health care system in the US where, 43 percent of children age six or younger are growing up in conditions that undermine their health.
Poor housing conditions can cause and exacerbate asthma through increased exposure to dust allergens, molds, cockroaches, rats, cold air, and dry heat. Likewise, children under age three whose families need but do not receive help paying their energy bills are 30 percent more likely to be hospitalized. In 2003, more than one in five families reported that they lacked enough nutritious food, and these “food insecure” families are at increased risk for poor health, illnesses requiring hospitalization, infection, malnutrition, and deficits in cognitive development, as well as behavioral and emotional problems.. Children who experience food insecurity are 30 percent more likely to be hospitalized by age three.
Government programs to assist low-income families have been shown to improve children’s health outcomes. These include Food Stamps and the Special Supplemental Food Program for Women, Infants, and Children (WIC), which promote increased prenatal care, improved infant weight and nutrition, and access to food. But many children who qualify for these programs are not participating due to lack of information on eligibility, administrative barriers (e.g. multiple verifications) and transportation barriers. Over 17 million Americans are eligible for, but do not receive, Food Stamps.
Despite these links and the availability of these services, physicians fail to screen patients routinely for their unmet resource needs, largely because they lack the knowledge or resources to address them. In a recent Johns Hopkins study, 98 percent of pediatric residents recognized that addressing patients’ socioeconomic needs can have positive health impact, but only 11 percent routinely screened for adequate food. In other words, doctors know that their patients have multiple non-medical problems, but have few solutions to offer. Just as doctors would not prescribe medicine without pharmacies, they will not ask patients whether they run out of food if they cannot “treat” this need.
At the same time, clinic-based social services are unable to keep pace with demand. There is a severe shortage of social workers who traditionally provide direct services, make referrals, and intervene in crisis situations. From 1996 to 2000, the percent of social workers based in hospitals declined from 20.8 to 7.9 percent. Social workers in health care report an increase in the severity of client problems, caseload size, paperwork and waiting lists for services. Their time is occupied by the deluge of families already struggling with child abuse, violence, and other crises, and they often do not have the time to avert potential crises—families who live tripled-up in an apartment or who need childcare to get a job. At Boston Medical Center, for example, where more than 50 percent of patients have incomes below $17,000, only one social worker serves the pediatric outpatient clinic’s 24,000 patients.
Rebecca believes that doctors must look beyond the clinic walls to put their low-income patients on a path to health. Since the pediatric clinic offers a unique opportunity—because both the child and a parent/adult have come to a “high trust” setting—college volunteers can step in to help pediatricians and other clinic providers identify and address unmet resource needs affecting the healthy development of these children and their families.
Project HEALTH’s clinic-based Family Help Desk offers a simple but effective solution: In clinics where our Family Help Desk programs operate, physicians can “prescribe” food, housing, job training, or other resources for their patients as routinely as they do medication. Located in the waiting room and staffed by college volunteers, our Family Help Desks “fill” these prescriptions by connecting patients with key resources. During designated “follow-up shifts,” volunteers then reach out to clients weekly via phone, mail, or e-mail to ensure they obtain the resources they need and address any linguistic, bureaucratic, or logistical hurdles. This follow-up may occur over a few weeks or as long as six months, depending on the scope of the client’s needs and the availability of the resources.
At many pediatric clinics, Project HEALTH is changing the intake process for each patient visit to include helping families complete a resources needs screen in addition to measuring a child’s height, weight, and other vital signs. The doctor and family review the completed screen, which is coded to generate referrals to social work, legal services, or the Family Help Desk. In many of the clinic sites, the Family Help Desk encounter is then recorded in the patient’s medical record like any other subspecialty referral. The assessment and encounter then become part of the medical record to facilitate the doctor’s follow-up.
Yet to achieve a health care system that addresses patients’ unmet resource needs and other social determinants of health requires not only new models of clinic-based infrastructure to meet those needs, but also the bold leadership to realize this vision for health care delivery. Project HEALTH provides an intensive, transformative experience to hundreds of college volunteers, creating a pipeline of new leaders with the conviction, knowledge, experience, and efficacy to change the health care system.
Project HEALTH engages in aggressive outreach and a rigorous application process to identify volunteers committed to addressing health and poverty, with the organization’s strong volunteer retention making this process more competitive—79 percent of non-graduating volunteers returned to Project HEALTH last year—such that it accepts as few as 15 percent of applicants in any year.
Working side-by-side with experienced physicians, lawyers, and social workers powerfully informs Project HEALTH’s volunteers’ understanding of how to effect change in health care. At the same time, the volunteers’ experiences negotiating the food stamps bureaucracy or searching for affordable housing provide insight into families’ assets and aspirations, as well as challenges they face in juggling health needs and other priorities. These sentinel experiences build volunteers’ skills, knowledge, and sense of efficacy in how to use the health care system as a gateway to address non-clinical needs.
In addition, all volunteers are required to participate in weekly “reflection sessions” that reinforce and contextualize the link between health and poverty. These sessions, which often include outside speakers, build community among the volunteer corps and provide a forum for volunteers to grapple with the challenges they witness in families’ lives, as well as to discuss program design and impact. Many Project HEALTH alumni go on to serve low-income patients – some in clinics where they once staffed the Family Help Desk or now spearhead efforts to replicate it. Having tackled the social determinants of health long before they learned its medical determinants, they practice a different kind of health delivery.
By tapping the “renewable resource” of college students’ time and energy, Project HEALTH provides a cost-effective solution to meet the needs of children and families. The result is a highly leveraged model: Project HEALTH’s 15 full-time staff supports 550 volunteers in serving over 14,600 children and adults annually. Project HEALTH also leverages in-kind support from its hospital partners, including space, telephone and internet access, postage, and payroll and benefits administration for Project HEALTH’s local staff. The result is not only the elimination of virtually all overhead costs from the organization’s cash budget, but also the full integration of our staff and programs into the clinical sites. Physically located in the clinics where our Family Help Desks operate and with full access to the hospitals’ email and electronic medical record systems, Project HEALTH’s staff are embedded in the health systems they seek to change. This value proposition has enabled Project HEALTH to secure from a number of its clinic sites not only the in-kind support detailed above, but also a portion of the organization’s operating costs.
With annual revenue of $2.9M and in-kind support of $1.4M, Project HEALTH’s 15 full-time staff and 550 volunteers serve over 14,000 children and adults a year at 16 Family Help Desks in Boston, Providence, New York, Washington D.C., Baltimore and Chicago. Through clinical partners, Family Help Desks are located in pediatric outpatient, adolescent, and prenatal clinics in addition to newborn nurseries, pediatric emergency rooms, health department clinics, and federally qualified health centers. Project HEALTH partners with the Medical-Legal Partnership (MLP) and other legal services, as well as with social workers in the clinics. Rebecca and her board are currently evaluating replication strategies and other expansion opportunities as part of a rigorous strategic planning process.
Rebecca was born in Boston, Massachusetts, to parents committed to issues of social justice and activism. Her father was a college professor, her mother a 6th grade teacher. Both had been active in the civil rights movement (her dad is a former VISTA volunteer), and imbued in her a strong sense of social justice. In Rebecca’s home, discussions about politics were daily fare. She remembers sitting on her dad’s shoulders at a rally for Geraldine Ferraro, the first woman candidate for Vice President, when her dad told her: “That could be you someday.”
As a freshman at Harvard, Rebecca volunteered in the housing unit of Greater Boston Legal Services. The intake interviews she conducted with families suffering intolerable housing conditions invariably led to concerns about the effects of these conditions on their health. A few days before turning eighteen, she read an article about Dr. Barry Zuckerman, chair of the Boston Medical Center (BMC) pediatric department, who was bringing lawyers, child psychologists, and other experts into the pediatric clinic so that vulnerable children could actually get healthy. Rebecca contacted him to suggest that students could provide a link between the clinic and the community resources that their patients need.
Dr. Zuckerman recommended that she first spend six months at BMC (a chaotic Level 1 trauma center) to deepen her experience. During that time, she trailed any doctor who would let her, spending afternoons in the pediatric outpatient clinic and neonatal intensive care unit and nights in the pediatric emergency room. The doctors told her that they’d prescribe antibiotics or an inhaler for their patients, knowing that there was no food at home or the family was sleeping in a car. With no idea how to find what the families needed, many had concluded that it was simply better not to ask. Rebecca went back to Dr. Zuckerman, and with him started Project HEALTH.
Rebecca had originally planned to work for social justice through the law. She was accepted to Harvard Law School, but deferred for a year, which turned into three, to stay with Project HEALTH. Project HEALTH was poised to become incorporated and enter a new phase of organizational development, and Rebecca believed that someone other than she was needed to lead the organization from that point forward. She entered law school but remained active by founding and leading Project HEALTH’s board.
In 2006, Rebecca returned to Project HEALTH hungry to realize her vision of health care systems change. She spent several months talking to all stakeholders to gain clarity about the challenges and opportunities facing the organization. From 2006 to 2008, Project HEALTH launched two new, highly-successful sites (in Baltimore and Chicago), tripled the size of the volunteer corps, and doubled the number of Family Help Desks in operation. Rebecca and Project HEALTH are now well poised to build on their successes and continue expanding and refining their model to achieve their vision of mobilizing thousands of young people to connect low-income patients with the resources they need to be healthy and creating the next-generation leaders committed to creating a health care system that delivers positive outcomes for all children and families.