Health Care Without Walls Inc.

Wellesley, MA   |  www.healthcarewithoutwalls.org

Mission

Health Care Without Wall’s mission is to improve the lives of women who are homeless or marginally housed through compassionate, high quality health care, education and advocacy.

Ruling year info

2000

Principal Officer

Dr. Roseanna H. Means

Main address

148 Linden Street, Suite 208

Wellesley, MA 02482 USA

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Formerly known as

Women of Means, Inc.

EIN

04-3487205

NTEE code info

Public Health Program (E70)

IRS filing requirement

This organization is required to file an IRS Form 990 or 990-EZ.

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Communication

Programs and results

What we aim to solve

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Our programs

SOURCE: Self-reported by organization

What are the organization's current programs, how do they measure success, and who do the programs serve?

Shelter-Based 'Gap' Health Care

In our core program, HCWW provides “gap” health care
for 1,800 homeless adult women at Rosie’s Place and Women’s Lunch Place, nearly a
third of whom are age 60 or older. HCWW volunteer physicians and nurses staff
nine weekday clinics and welcome clients on a drop-in basis. They offer
diagnostics, referrals and health education. 
Our team helps our clients stay on top of hypertension (blood pressure),
diabetes (blood sugar) and skin and musculoskeletal conditions that are common
for homeless women. This past year, our clinicians at Women’s Lunch Place and
our nursing students at Rosie’s Place also offered weekly progressive muscle
relaxation classes, guided meditation classes, reiki, a walking group and four
presentations on women’s health issues.  pasting

Population(s) Served

Phase I of Bridges to Elders ran from 2013-2016 and was a partnership between HCWW and Commonwealth Community Care (CCC), supported by an Accountable Care Organization (ACO) contract with Commonwealth Care Alliance (CCA). During
that project, HCWW hired a Community Health Worker who worked with a Nurse Practitioner/Physician primary care team from CCC to provide primary care and care coordination to 45
impoverished women that we referred from the shelters.  These women were 65+ of age and had Medicare and MA Health Standard.  During the three years of the project, we were able to reduce ER visits by 86% and inpatient
hospitalizations by 77%, compared to established
benchmarks.  Phase II of Bridges to Elders began in January 2017 when we hired a CHW to reach out to women 60+ years at Women’s Lunch Place. She is supported by a part-time nurse practitioner who oversees the clients’ clinical conditions and reports back to their primary care physicians. In Phase I of Bridges to Elders, the CHW was in the field, stopping only occasionally at the shelters because she was splitting her time between Women’s Lunch Place and Rosie’s Place. Now that we have embedded a CHW right in the shelter where she is more visible to the guests, she has been able to nearly double the number of clients that she can see: currently 75 in the first 8 months of 2017.In 2018, HCWW will take Bridges to Elders to the next level, with the goal of demonstrating impact on managing chronic disease-related illnesses among our adult and aging clients in the Boston shelter clinic program and reducing ER visits and hospital admissions. With comprehensive data gathered at the end of 2018, we plan to secure an ACO contract or social impact funding to create a sustainable model. Over the next year, we will launch the following activities: 1) Add a second NP/CHW team at Rosie’s Place to complement the successful implementation of such a team at Women’s Lunch Place and track impact (HCWW is modifying its clinical database to include ICD-10 diagnosis codes to capture the HCWW clinicians’ evaluations and treatment of these common conditions. 2) Secure contracts from 1-2 payors for the evaluation and treatment “bridge” care of chronic diseases that HCWW provides in the shelter clinics. 3) Track the number of encounters and diagnoses. And 4) Get feedback from the PCPs and Medicaid claims data to assess overall impact.

Population(s) Served

14.0pt;mso-bidi-font-weight:bold">In September 2017, HCWW launched its Calibri;mso-bidi-font-family:"Times New Roman"">Family Shelter Care Program in
Framingham.  Here, HCWW provides ‘gap’
care to homeless families, primarily single mother-headed households with
children. Previously, HCWW served families living in motel shelters in Waltham
and Danvers, until the state closed the program in late 2016 (although we still visit families at Mary's House in Waltham).  Now, HCWW is partnering with South Middlesex
Opportunity Council (SMOC), a multi-service anti-poverty agency in Framingham.  HCWW will serve 45 families and their children who have been geographically
disconnected from regular medical providers. 
HCWW offers two clinic evenings a week and our goal is to help
residents improve their health with self-care coaching, avoid emergency room
visits and guide them to follow-up with their primary care. pasting

Population(s) Served

"Times New Roman"">Bridges to Moms began
in January 2016. Our clinical team, which includes a physician, nurse
practitioner and Community Health Worker (CHW) provides intensive care
management for pregnant and post-partum homeless women enrolled at the Brigham
and Women’s Hospital with the goal of improving health and birth outcomes and
maternal bonding. Through September 30th of this year, 69 women have
been referred to the program. Sixty-six babies have been born to date.  Of the completed pregnancies, 80% of the
prenatal appointments were attended. Seven of the moms went to 100% of their
prenatal appointments. The post-partum appointment attendance rate is 67%.
Typically, in this population, less than 10% of prenatal and nearly zero
post-partum appointments are kept. In addition to the unexpectedly high
percentage of clinic appointments achieved, we are also thrilled to discover
that some of the moms are working hard to move their lives forward by taking
classes, earning their GEDs, obtaining a certificate from a course, etc. We are
now tracking these accomplishments as a reflection of ‘forward mobility.’  The data point is being referred to as a
‘mobility index.’  pasting

Population(s) Served

HCWW mentors more than 100 medical students, nursing students and medical residents per year. Each trainee receives a copy of Medical Care for Homeless Women: A Curriculum for Novice Providers, written by HCWW. We prepare clinicians to be compassionate caregivers who are skilled at meeting the needs of the underserved.

Population(s) Served

Where we work

Awards

Our results

SOURCE: Self-reported by organization

How does this organization measure their results? It's a hard question but an important one.

Number of clients served

This metric is no longer tracked.
Totals By Year
Population(s) Served

No target populations selected

Related Program

Shelter-Based 'Gap' Health Care

Type of Metric

Output - describing our activities and reach

Direction of Success

Holding steady

Context Notes

This metric includes the clients in all of the programs. In 2018 we eliminated the Family Shelter program which accounts for the drop in clients served.

Number of overall donors

This metric is no longer tracked.
Totals By Year
Population(s) Served

No target populations selected

Type of Metric

Input - describing resources we use

Direction of Success

Increasing

Goals & Strategy

SOURCE: Self-reported by organization

Learn about the organization's key goals, strategies, capabilities, and progress.

Charting impact

Four powerful questions that require reflection about what really matters - results.

Health Care Without Walls (HCWW) offers free, “bridging” health care to homeless women and their children in Greater Boston area shelters, safe houses and family transitional housing sites. This model is a Free Care Program which allows our clients to be seen as walk-ins in the shelter where other survival needs are being met. Formal registration and billing are intentionally set aside in order to improve access, build trust, and reduce as many bureaucratic barriers as possible. Ultimately, our goals include: Improving the health status and quality of life of homeless women and their children; Increasing the number of clinicians trained and dedicated to treating the poor;Meeting the changing health care needs of homeless women aging in the shelter system; and Enhancing the depth of our health care management services.   HCWW measures success by-- (i) meeting program utilization and medical trainee target numbers, (ii) increasing 'milestone' health behaviors such as taking medication as instructed; following through with a medical appointment; or completing a psychiatric exam; (iii) improving patients' clinical metrics such as blood pressure, blood sugar (diabetic women), or annual flu shot compliance; and (iv) setting and achieving health-related goals, such as reducing isolation and depression and improving medication understanding and compliance.

Since our inception, Health Care Without Walls (HCWW) has received statewide and national recognition for our novel and cost-savings approach to the care of homeless women. We have always taken the long view, recognizing that there are no quick fixes and that the key to a successful outcome is developing a trusting relationship. The following strategies and activities are the building blocks for our success today and in the future.   I. Shelter-based 'gap' health care is delivered by HCWW volunteer physicians and part-time, paid nurse care managers at Greater Boston clinics on a drop-in basis. They provide diagnostics, treatment, referrals and health education to fill the gap that exists between the needs of this population and their level of access to the health care system. In 2019, we will serve 1,700 women and children.   II. Community Health Workers provide culturally competent outreach, case management, individualized health education, patient navigator services, social supports, and advocacy for our most vulnerable populations – homeless elderly women and pregnant and post-partum homeless women who are patients at Brigham and Women’s Hospital.   III. Patient navigator services are provided to patients with cognitive impairments and/or mobility problems who need accompaniment to appointments at hospitals, laboratories, or specialists.   IV. Medical training and education are provided to over 100 medical and nursing students and medical residents each year. Each trainee receives a copy of "Medical Care for Homeless Women: A Curriculum for Novice Providers," written by HCWW. The HCWW team prepares clinicians to be compassionate caregivers who are skilled at meeting the needs of the underserved, and we emphasize the important role of volunteerism as a way to effect social change.   V. HCWW’s special programs meet the complex health needs of two vulnerable populations: elderly homeless women and pregnant and post-partum mothers and their babies. Through our Bridges to Elders Program, HCWW acts as the primary care ‘medical home’ to 80 Medicare and MA Medicaid eligible women. Bridges to Moms, launched in 2017, has become a successful program with documented health improvement indicators. It serves homeless pregnant and post-partum women and their babies at Brigham and Women’s Hospital – with the goal of improving health outcomes and maternal bonding.

While there are many Boston-based social service agencies providing some services to homeless women and families, many of them operate independently, siloed by their singular missions. To our knowledge there are no programs that are focused exclusively on the holistic approach that HCWW takes with homeless women: identifying, tracking and closing the gaps between what happens to her when she walks away from the HCWW clinician at one of our sites (i.e. shelter, safe house, etc.) until we see her again. HCWW staff are, literally, the “human passports” that link the internal and external services and programs to the client, seeing her as a whole.   HCWW's staff team is led by Dr. Roseanna Means, who has practiced primary care on the staff of Brigham and Women’s Hospital for 30 years and was the former medical director of Boston Health Care for the Homeless. She has been identified by the Robert Wood Johnson Foundation as a 2010 Community Health Leader for developing a model for homeless health care delivery and has also been recognized by Harvard Medical School for her dedication to teaching and mentoring medical students about the care of homeless women. Dr. Means oversees our clinical team and is spearheading HCWW’s new Bridges to Moms pilot. HCWW’s 17 volunteer physicians are accomplished, dedicated, and are affiliated with pre-eminent teaching institutions and health systems in the Boston area. They bring a range of specialty expertise including internal medicine, family medicine, pediatrics, psychiatry, OB/GYN, dermatology, and emergency medicine. In addition, HCWW maintains a paid staff of 16 part-time nurse care managers. The nurses support our volunteer physicians and provide responsive medical care and care management in our shelter-based clinics. The clinical staff is multilingual speaking Spanish, Portuguese, and Haitian Creole. We have two multi-lingual, community health workers, both of whom are from Boston and bring cultural competence and essential experience accessing community resources. One works with our elderly homeless women at Rosie’s Place and Women’s Lunch Place. She provides outreach, health education, linkages to community resources, and care management in conjunction with the nursing team. The other has just started with our Bridges to Moms program and provides assistance to pregnant and post-partum women at Brigham and Women’s Hospital, with phone calls, transportation, and accompaniment to prenatal visits as well as specialist and laboratory appointments. Finally, HCWW is governed by a diverse Board of Directors who provide fiscal and administrative oversight and offer core professional skills. All ten Board members donate funds and broaden the organization's visibility. The Board meets bi-monthly and holds an Annual Meeting in January. HCWW also receives guidance from a 3-member Executive Advisory Board that provides professional advice and connections.

In 2015, Health Care Without Walls changed its name to reflect the evolution of our organization, highlighting our commitment of bringing health care directly to where it is needed most – beyond traditional medical facilities. HCWW has created and mobilized a community of long-term serving, volunteer physicians and sustained a modest nursing staff in order to respond to the unmet health care needs of homeless women who have fallen through Boston's health care safety net, despite abundant resources. We have provided free medical care via more than 100,000 clinical encounters to homeless women and their children in up to 12 shelters and safe houses. In addition, HCWW has trained nearly 1,000 medical and nursing students and residents in the principals of trauma informed, compassionate care.   As we look ahead to the future, HCWW seeks to demonstrate that contracting with an Accountable Care Organization (ACO) for program services under a global payment contract for it's Bridges to Elders and Bridges to Moms programs. It has shown that it can improve health and save medical costs for these special populations of homeless women. We believe that this “community of services” would fit the criteria for a global payment, creating a sustainable payment model for intensive case management and comprehensive health services, leading to improved health outcomes.

Financials

Health Care Without Walls Inc.
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Operations

The people, governance practices, and partners that make the organization tick.

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  • Analyze a variety of pre-calculated financial metrics
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Health Care Without Walls Inc.

Board of directors
as of 5/23/2019
SOURCE: Self-reported by organization
Board chair

Ms. Karen Matjucha

Deloitte Consulting, LLP

Term: 2017 - 2018

Karen Matjucha

Principal, Deloitte Consulting, LLP

Sarah Troiano

Community Volunteer

Kristen Ferris

Attorney, Morgan, Lewis and Bockius, LLP

Laura Quimby

Medical Director, Essex County Correctional Facility

Mary Grant

Adjunct Faculty, Regis College & Endicott College

Omonigho (Omo) Omokwale

Deloitte Consulting, LLP