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Whittier Street Health Center Committee, Inc.

 1290 Tremont Street
 Roxbury, MA 02120
[P] (617) 427-1000
[F] (617) 858-2674
Administration Office
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EIN 04-2619517

LAST UPDATED: 01/04/2019
Organization DBA Whittier Street Health Center
Former Names --
Organization received a competitive grant from the Boston Foundation in the past five years No


Mission StatementMORE »

The mission of Whittier Street Health Center is to provide high quality, reliable and accessible primary care and support services to promote wellness and eliminate health and social disparities.

Mission Statement

The mission of Whittier Street Health Center is to provide high quality, reliable and accessible primary care and support services to promote wellness and eliminate health and social disparities.

FinancialsMORE »

Fiscal Year July 01, 2015 to June 30, 2016
Projected Income $27,200,082.00
Projected Expense $26,533,030.00

ProgramsMORE »

  • Primary Care for Boston Residents

Revenue vs. Expense ($000s)

Expense Breakdown 2016 (%)

Expense Breakdown 2015 (%)

Expense Breakdown 2014 (%)

For more details regarding the organization's financial information, select the financial tab and review available comments.


Mission Statement

The mission of Whittier Street Health Center is to provide high quality, reliable and accessible primary care and support services to promote wellness and eliminate health and social disparities.

Background Statement

Whittier Street Health Center was established in 1933 as a well-baby clinic in the Boston neighborhood of Roxbury. Whittier is a Federally Qualified Community Center (FQHC), accredited by the Joint Commission, recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 Patient-Centered Medical Home (PCMH), and licensed by the Massachusetts Department of Public Health.

Whittier serves 27,000 patients and community residents through a range of services that address the primary care, behavioral health, dental care, vision, and social service needs of our community. Our coordinated care delivery model uses multidisciplinary teams staffed by physicians, nurses, and medical assistants. The teams are supported by clinical pharmacists, nutritionists, and case managers.
As a community health center dedicated to improving the health and wellness of the community, Whittier also provides free programs to improve the health and wellness of the surrounding neighborhoods, which struggle with poverty, violence, and the other social determinants of health. Our programming is always informed by our annual Community Needs Assessments, community input, and regular stakeholder meetings.
In January 2012, Whittier opened its newly constructed, Silver LEED-certified, 78,900-square foot health facility, partly funded through a $12 million HRSA American Recovery and Reinvestment Act grant. The new building gives us the capacity to provide up to 220,000 visits annually, or about 80,000 patients. In addition to primary care and improved handicap access, the new facility provides a holistic array of services in one location, such as a Community Resource Room for community events, an Urgent Care Clinic, expanded Dental Services, a 340B pharmacy, specialized clinics for chronic illnesses prevalent among our patients, and others.

Impact Statement

 2017 Top Five Accomplishments

1.Whittier provided care to nearly 30,000 patients,conducted 111,240 clinic visits and 22,000 community outreach visits, and provided $2,267,000 in free care.

2. Opened Whittier@Quincy Commons, a satellite clinic on Blue Hill Avenue, staffed by two full-time doctors, who provide scheduled appointments as well as walk-in services. This new clinic also has a pharmacy.

3. Achieved or exceeded 10 of 16 Best Practice/National Benchmarks for quality of care.

4. 91% of our Medical and Dental patients rate their satisfaction with our services as good or excellent 96% of our Behavioral Health patients rate their satisfaction with our services as good or excellent.

5. Ranked in The Boston Globe’s Top 100 Women–Led Businesses in Massachusetts for the fourth consecutive year.

2018 Goals 

1. Increase capacity in the Pediatrics and Dental Departments.

2. Expand food access with creation of a food pantry and a rooftop garden to increase produce production.

3. Sustain mission-aligned grant-funded programs through a diverse mix of funding sources.

4. Continue implementing the Health Equity Program and achieve improved outcomes for patients.

5. Continue hosting successful community and fundraising events.


Needs Statement

  1. Continue to prioritize funds development to secure the resources needed to develop, implement and grow services and programs that achieve the goals of the organization and increase overall fundraising outcomes.
  2. Establish clinical and non-clinical indicators and benchmarks in order to measure report outcomes.Utilize data collection and analysis in order to define best practices.
  3. Form collaborative relationships that align with and support the achievement of our organization’s strategic objectives.
  4. Provide training and supplemental supports for leadership development that respond to the current and emerging needs of the organization and broader community. Implement a system of succession planning that responds to the need for future and competent leaders. 
  5. Effectively manage a comprehensive funds development plan that will enable the timely implementation of our strategic plan and meet ongoing financial needs over the next five years.

CEO Statement

We are eager to forge ahead in making sure that our health facility turns the page on health and social disparities and shapes the next chapter in health care by becoming the paradigm for health equity in our Roxbury environs and beyond.

With our Boston Health Equity Program, we are starting to change community health care delivery with a model of care that produces far better health results at less cost than the current system. With our standout, state-of-the art health center, we can capitalize on our visibility and leverage our patient-centered model to connect with the people who have so many problems that their health is not necessarily top priority. Our model of care addresses many factors that affect health such as family and income stresses, challenging living conditions and unhealthy behaviors. We take responsibility for the condition of the whole person: physical, mental, social and ensure that our patients are partners in their own health and wellbeing.

Our 78,900 square-foot, six-story, Silver LEED-certified green building was built around patient-centered, team-based care, each primary care team has its own clinic, reception area and assigned staff to ensure that every patient has a medical home. We are readily accessible and part of patients’ and resident’ daily lives and embedded in the fabric of the community.

With our new building, we have expanded our dental services, urgent care clinic, pharmacy and number of provider exam rooms. We now offer mammography and physical therapy onsite. We open our doors to community residents by providing a large Community Education Room to hold community meetings to address violence prevention, health, economic development, jobs, housing, and various other topics. We also added group education rooms to host our medical group visits that address mental health, chronic illnesses, infant mortality and a multitude of health issues. Our groundbreaking partnership with Dana-Farber Cancer Institute provides holistic cancer care in the heart of our patients’ community.

With our comprehensive model of care that focuses on health engagement and outreach, education, wellness support, public health and primary care, it is our goal to make sure our patients feel welcomed, cared for, and secure when they walk through our doors. 

Board Chair Statement


Geographic Area Served

In a specific U.S. city, cities, state(s) and/or region.
City of Boston- Jamaica Plain
City of Boston- Mattapan
City of Boston- Roxbury
City of Boston- South Boston
City of Boston- Citywide (Indiv. neighborhoods also listed)

Whittier Street Health Center serves the Boston neighborhoods of Roxbury, Dorchester, Mattapan, Jamaica Plain, Hyde Park, South End, and the surrounding communities.

Organization Categories

  1. Health Care - Community Health Systems
  2. -
  3. -

Independent research has been conducted on this organization's theory of change or on the effectiveness of this organization's program(s)



Primary Care for Boston Residents

As a Section 330 Federally Funded Health Center, Whittier Street Health Center is funded to provide primary care to Boston residents from diverse backgrounds. Whittier Street Health Center has more than 40 health care, social services and wellness programs to meet the holistic health needs of our patients. The core services include Urgent care, Adult medicine, Eye care, Family medicine, Oral health, OB/GYN, Orthopedics, Pediatrics and Adolescent health, Arts Therapy (drama, music and art therapy), Podiatry, Geriatrics, Physical Therapy, Radiology, Mental Health and Substance Abuse Counseling, Pharmacy Medical Interpreters, Specialized Clinics to address Diabetes, Cardiovascular disease, HIV and Infectious Diseases, Developmental Disability, Pediatric Asthma and Obesity Services, Post-Prison Release/Community Re-entry Services for ex-offenders, Men's Health, W.Y.S.E. (Youth Development Program), HIV/AIDS, refugee health assessment, and domestic violence prevention and education.

Budget  N/A
Category  Health Care, General/Other Quality of Health Care
Population Served At-Risk Populations People/Families of People with Health Conditions Minorities
Program Short-Term Success 

Whittier has established a five year plan through our Boston Health Equity Project.

By 2017 Whittier would like to:
  • Increase number of patients from 25,000 to 40,000
  • Exceed national standards in screening for cancer, cardiovascular disease, depression, and diabetes.
  • Engage 100% of youth in prevention and wellness support programs
  • Ensure that at least 80% of youth with chronic illness/problems are under control
  •  Reduce 95% of WSHC patients inappropiate use of the emergency department
Program Long-Term Success  Whittier Street Health Center has launched the Boston Health Equity Project. This project is starting to change community health care delivery with a model of care that produces far better health results at less cost than the current system.
Program Success Monitored By 
Whittier Street Health Center uses an Annual Quality Assurance Dashboard which measures our programs success.We also utilized an external evaluation service, Press Ganey to measure patient satisfaction. We assess community needs and public health issues through our annual community needs assessment which informs the development of our innovative programs and services.

Examples of Program Success 

Kaiser Health News, using 2010 data from the U.S. Health Resources and Services Administration, recently issued a report measuring the quality of care at the nearly 1,200 community health centers in the country. Whittier exceeded the National average in five out of the six categories. The National average of all newborns that fall into the low birth weight category is 8.3% and Whittier’s was only 2.27%.

  •  Among the 36 community health centers in Massachusetts, Whittier is in the top 3 at fighting hypertension and top 10 for prenatal care.
  • While these outcomes demonstrate our accomplishments, there are still significant disparities in the communities we serve. By meeting a series of ambitious but reasonable goals, the Boston Health Equity Project will bring wellness to communities that have too often been left out of the health and well-being equation.

CEO/Executive Director/Board Comments


Whittier works closely with our patients, who face high rates of chronic disease, to address inequitable health disparities and control rising health care costs. Some of our challenges include:

  • 35% of our patients are uninsured
  • High demand for medical, behavioral health, and dental services;
  • Nearly 70% of Whittier’s patients 18 and older have been diagnosed with diabetes, cancer, hypertension, asthma, HIV, or obesity. Approximately 80% have psychosocial issues. Patients with these conditions are more than twice as likely to have visited the ER or been admitted to a hospital within the past year.
  • Coupled with depression, these diseases are physically, psychologically and economically debilitating.
We are here to meet the needs of our community: We launched our Boston Health Equity Program to increase patient access, meet or exceed national standards for screenings and early detection, reduce unnecessary use of ER and hospitals, and ensure that 100% of our patients are effectively case managed after they are discharged from the hospital.
  • Of the 10 Refugee Health Assessment sites in Massachusetts, Whittier is one of two located in Boston, fortifying our position in the immigrant and refugee community.
  • We are one of 62 health centers in the nation federally funded to provide care to public housing residents and the only one located in Boston addressing issues of disenfranchisement related to drugs, poverty, chronic disease, disability, blight, fragile family structures, crime, and unemployment for residents.
  • Established Centers of Excellence in Diabetes Prevention and Management, Obesity, Cancer Prevention, Art Therapy, Men’s Health and Asthma.
  • Remained on the cutting edge of technology. Whittier implemented an Electronic Medical Records system in 2003, which helps with effectiveness of care. Additionally, the optometry department recently added an OCT imaging device to better screen our patients for eye diseases.
  • In partnership with Dana-Farber Cancer Insitute, Whittier opened a Community Cancer Center and Mammography Suite to address cancer disparities in minority and low income communities.


CEO/Executive Director Ms. Frederica M. Williams
CEO Term Start Jan 2002
CEO Email
CEO Experience

Frederica M. Williams, President and CEO of Whittier Street Health Center, has transformed a basic community health center into a neighborhood centerpiece and national model. Her keen vision has positioned Whittier as a leader in urban health care focusing on high quality and cost effective healthcare and social services for diverse populations. Williams has 25 years of experience in health care administration and finance.

Williams takes the health of Boston’s neediest residents to heart and is highly engaged in supporting improvements in the health of diverse immigrant populations living in Massachusetts as well as eliminating health and social disparities among minorities. She is an advocate extraordinaire and a compassionate and caring leader who is deeply committed to improving the lives of vulnerable and low income residents of Boston.

Williams has brought a focus on addressing the health and social disparities that impact the health of the communities served, creating equitable access to high quality health care, social services and public health services and sound financial stewardship to Whittier to ensure that the services and resources offered by Whittier will be available for generations to come. Since Williams began at Whittier in 2002, the number of people served has increased from 5,000 to 25,000 in 2013 and her vision is to serve 40,000 by 2017. Despite the increase in patients and the wide range of free services provided to community residents, the center has consistently remained viable through improvements in operations, diversification of funding sources, fundraising and the development of entrepreneurial services. 

She attended the London School of Accountancy, obtained a graduate certificate in Administration and Management from the Harvard University Extension School and a Master in Business Administration with a concentration in Finance from Anna Maria College.  

She is a Corporate Director of the Eversource Energy, NYSE (ES), serves on the board of the Dana-Farber Cancer Institute, and is a member of the Massachusetts Women’s Forum, International Women's Forum and Women Business Leaders in Health Care.
Co-CEO --
Co-CEO Term Start --
Co-CEO Email --
Co-CEO Experience --

Former CEOs and Terms

Name Start End
-- -- --

Senior Staff

Name Title Experience/Biography
Lewis Keith Abbott Director of Human Resources --
Janet Gibson Boswell Director of Development --
Dr. Sameer Chinoy Chief Medical Officer --
Dr. Narulla Diyant Director of Oral Health Services --
Jim Lee Vice President of Finance and CFO --
Michael Ndungu Chief Information Officer --
Christine Pajarillo Director of Behavioral Health Services --


Award Awarding Organization Year
Top 100 Women-Led Businesses in Massachusetts The Boston Globe Magazine 2017
LEED Silver US Green Building Council 2012
Patient centered medical home National Committee for Quality Assurance (NCQA) 2012


Affiliation Year
-- --
Member of state association of nonprofits? Yes
Name of state association Massachusetts Nonprofit Network

External Assessments and Accreditations

External Assessment or Accreditation Year
American Diabetes Association - Accreditation --
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - Long Term Care Accreditation --


Boston Housing Authority, Bay State Physical Therapy, Bell Tower Foods, Dana Farber Cancer Institute, Boston Children’s Hospital, Somali Development Center, Lower Roxbury Coalition, South Bay House of Corrections, Boston Public Schools, Brigham and Women’s Hospital, Boston Medical Center, and Faith Community Based Organizations.

CEO/Executive Director/Board Comments

Where Investment and Advocacy Are Needed

Much of the model of care that Whittier will rely on to make good on the promise of the Boston Health Equity cause is largely in place, and its potential for success is reflected in the dramatic growth of the center’s patient population. However, further innovations will strengthen Whittier's capacity to improve community health on a much larger scale. 

Whittier innovations requiring additional financial resources include:

  1. A Medical Fitness Center within the new health center to provide wellness activities, education and support that is prescribed and followed up by patients’ primary care teams. (The wellness center provides a compelling focus for near-term fundraising and an outstanding naming opportunity.)
  2. Community-based “virtual clinics” that are linked with the main patient facility. The clinics will offer easily accessible entry to care and health monitoring via basic screening tests, health guidance, and visit scheduling. Enhance these resources with community health ambassadors, who promote health and help residents access care, and patient navigators, who help them follow through on visits, medications, and wellness activities.
  3. A new lab, scheduling, and medical record technologies that allow primary care teams real-time information on each patient’s health status to make their visits more productive, reduce staff follow up time and streamline the number of visits patients must take time out of their challenging lives to make. EHRs will integrate clinical, mental health and wellness information in order to achieve well-coordinated, comprehensive care; assists information sharing between Whittier Street and providers of specialty care; and supports outcome tracking and quality improvement.
  4. Developing collaborations with academic medical centers to better integrate primary care, specialized care, wellness and psychosocial support, improve access to clinical trials, and ensure better long-term outcomes for patients requiring hospitalization. Whittier Street Health Center has already begun such collaboration with Dana-Farber Cancer Center.
  5. Partnerships with the Boston Public School System to integrate a strong health focus into the curricula and school programming. This will provide young people with a solid foundation of health knowledge and will help build from the bottom up a community culture that prioritizes wellness.

Foundation Comments


Staff Information

Number of Full Time Staff 171
Number of Part Time Staff 44
Number of Volunteers 0
Number of Contract Staff 22
Staff Retention Rate % 94%

Staff Demographics

Ethnicity African American/Black: 115
Asian American/Pacific Islander: 10
Caucasian: 59
Hispanic/Latino: 46
Native American/American Indian: 1
Other: 3
Other (if specified): --
Gender Female: 167
Male: 67
Not Specified 0

Plans & Policies

Organization has Fundraising Plan? Yes
Organization has Strategic Plan? Yes
Years Strategic Plan Considers 5
Management Succession Plan Yes
Business Continuity of Operations Plan Yes
Organization Policies And Procedures Yes
Nondiscrimination Policy Yes
Whistle Blower Policy No
Document Destruction Policy --
Directors and Officers Insurance Policy --
State Charitable Solicitations Permit --
State Registration --

Risk Management Provisions


Reporting and Evaluations

Management Reports to Board? No
CEO Formal Evaluation and Frequency Yes Annually
Senior Management Formal Evaluation and Frequency Yes Annually
Non Management Formal Evaluation and Frequency Yes Annually


Board Chair Mr. Vernon Nelson
Board Chair Company Affiliation Milton High School
Board Chair Term Jan 2015 - Dec 2017
Board Co-Chair Pastor Gerald Bell
Board Co-Chair Company Affiliation Department of Housing and Community Development
Board Co-Chair Term Jan 2015 - Dec 2017

Board Members

Name Company Affiliations Status
Mr. True See Allah Suffolk County Sheriff's Department Voting
Ms. Omolara Bankole Retired Voting
Pastor Gerald Bell Department of Housing and Community Development Voting
Ms. Donna Delotta Year Up Voting
Mr. Craig Estes Middlesex County Voting
Mr Vernon Nelson Retired Voting
Ms. Vianka Perez Belyea Beth Israel Deaconess Medical Center Voting
Ms. Cindy Walker Community Volunteer Voting
Ms. Alicia Wedderburn Community Volunteer Voting
Ms. Frederica M. Williams Whittier Street Health Center Exofficio

Constituent Board Members

Name Company Affiliations Status
-- -- --

Youth Board Members

Name Company Affiliations Status
-- -- --

Advisory Board Members

Name Company Affiliations Status
Mr. John Jenkins West Insurance Agency --
Dr. Gene Lindsey Atrius Health (CEO Emeritus) --
Mr. Richard Lynch CeltiCare Insurance --
Ms. Colette Phillips Colette Phillips Communications --
Mr. Matthew Shadrick Eastern Benefits --
Mr. Marc Spooner Tufts Health Plan --

Board Demographics

Ethnicity African American/Black: 7
Asian American/Pacific Islander: 1
Caucasian: 1
Hispanic/Latino: 1
Native American/American Indian: 0
Other: 0
Other (if specified): --
Gender Female: 6
Male: 4
Not Specified 0

Board Information

Board Term Lengths 3
Board Term Limits --
Board Meeting Attendance % 90%
Written Board Selection Criteria Yes
Written Conflict Of Interest Policy Yes
Percentage of Monetary Contributions 100%
Percentage of In-Kind Contributions --
Constituency Includes Client Representation Yes

Standing Committees


CEO/Executive Director/Board Comments

Whittier Street Health Center's Community Board is composed of patients and other stakeholders. They meet every month and vote on action items presented by Whittier executive staff.
The Health and Wellness Foundation Board includes volunteers who help with the fundraising activities. They meet quarterly, contribute financially, and foster philanthropic relationships on behalf of the health center. 

Foundation Comments



Revenue vs. Expense ($000s)

Expense Breakdown 2016 (%)

Expense Breakdown 2015 (%)

Expense Breakdown 2014 (%)

Prior Three Years Total Revenue and Expense Totals

Fiscal Year 2016 2015 2014
Total Revenue $26,129,158 $24,505,844 $23,119,533
Total Expenses $23,840,728 $22,447,771 $21,360,769

Prior Three Years Revenue Sources

Fiscal Year 2016 2015 2014
Foundation and
Corporation Contributions
-- -- --
Government Contributions $6,823,794 $6,229,326 $4,462,520
    Federal -- -- --
    State -- -- --
    Local -- -- --
    Unspecified $6,823,794 $6,229,326 $4,462,520
Individual Contributions $2,593,767 $2,426,707 $3,312,943
Indirect Public Support $0 $0 --
Earned Revenue $15,246,472 $14,469,087 $13,882,575
Investment Income, Net of Losses $601,975 $601,887 $601,471
Membership Dues $0 $0 --
Special Events $372,514 $333,748 $440,715
Revenue In-Kind -- -- --
Other $490,636 $445,089 $419,309

Prior Three Years Expense Allocations

Fiscal Year 2016 2015 2014
Program Expense $17,303,235 $19,539,142 $18,114,926
Administration Expense $6,346,757 $2,708,533 $3,076,131
Fundraising Expense $190,736 $200,096 $169,712
Payments to Affiliates -- -- --
Total Revenue/Total Expenses 1.10 1.09 1.08
Program Expense/Total Expenses 73% 87% 85%
Fundraising Expense/Contributed Revenue 2% 2% 2%

Prior Three Years Assets and Liabilities

Fiscal Year 2016 2015 2014
Total Assets $33,464,262 $29,710,979 $27,073,814
Current Assets $31,394,399 $27,884,640 $26,528,370
Long-Term Liabilities $9,000,000 $9,000,000 $9,000,000
Current Liabilities $1,434,078 $1,574,580 $995,488
Total Net Assets $23,030,184 $19,136,399 $17,078,326

Prior Three Years Top Three Funding Sources

Fiscal Year 2016 2015 2014
1st (Source and Amount) -- --
-- --
-- --
2nd (Source and Amount) -- --
-- --
-- --
3rd (Source and Amount) -- --
-- --
-- --

Financial Planning

Endowment Value --
Spending Policy N/A
Percentage(If selected) --
Credit Line Yes
Reserve Fund No
How many months does reserve cover? --

Capital Campaign

Are you currently in a Capital Campaign? No
Capital Campaign Purpose --
Campaign Goal --
Capital Campaign Dates -
Capital Campaign Raised-to-Date Amount --
Capital Campaign Anticipated in Next 5 Years? --

Short Term Solvency

Fiscal Year 2016 2015 2014
Current Ratio: Current Assets/Current Liabilities 21.89 17.71 26.65

Long Term Solvency

Fiscal Year 2016 2015 2014
Long-term Liabilities/Total Assets 27% 30% 33%

CEO/Executive Director/Board Comments

Whittier’s patients are predominantly low income, uninsured, and under-insured. Approximately 35% of Whittier’s patients have no insurance. Whittier provides all of its social services and wellness programs for free. The demand for our services is increasing because of our demonstrated success in addressing health and social disparities in the communities we serve. We also ensure program sustainability by evaluating our grant funded programs on a number of different levels prior to implementation. These sustainability criteria include our:

  • Ability to attract grant dollars through measurable and replicable outcomes;
  • Ability to generate revenue for the Health Center in the long term to pay for non-billable aspects of the program;
  • Buy-in from administrative leadership.

Patient navigation services that improve health outcomes for our patients are beneficial to the long-term health of the health care industry as costs related to chronic diseases are reduced with earlier diagnosis and management. Whittier anticipates many aspects of the program may be covered through payment reform in the future.

Whittier Street Health Center is currently participating in a Patient-Centered Medical Home demonstration project that includes a pilot of a global payment structure. Whittier believes that Massachusetts reform is headed towards a global payment structure where Whittier will be paid by the patient, rather than by the service, with incentives for clinical outcomes and high quality, cost effective care. As part of this payment, Whittier anticipates that support services, including patient outreach and navigation, will be included.

Foundation Comments

Financial summary data in the charts and graphs above are is the organization's IRS Form 990s.  Contributions from foundations and corporations are listed under individuals as the breakout was not available.
*Please note that the 990 data represents the health center, but not the associated foundation, which is included in the audited financials. 


Other Documents

Annual Report (2015)


The Impact tab is a section on the Giving Common added in October 2013; as such the majority of nonprofits have not yet had the chance to complete this voluntary section. The purpose of the Impact section is to ask five deceptively simple questions that require reflection and promote communication about what really matters – results. The goal is to encourage strategic thinking about how a nonprofit will achieve its goals. The following Impact questions are being completed by nonprofits slowly, thoughtfully and at the right time for their respective organizations to ensure the most accurate information possible.

1. What is your organization aiming to accomplish?

The goal of Whittier Street Health Center is to champion equitable access to high quality care, and to eliminate health and social disparities.

2. What are your strategies for making this happen?

The social determinants of health—such as poverty, crime, and education—often act as barriers to forming or maintaining lifelong healthy habits that would allow the city’s most vulnerable residents to prevent or manage preventable chronic conditions such as diabetes and obesity. To address these inequities in access to high quality care, Whittier Street Health Center designed and implemented the Boston Health Equity Program (BHEP), a primary care delivery model that combines care coordination, community outreach, and wellness support. BHEP's goals are modeled on the Triple Aim framework adopted by the Centers for Medicare and Medicaid: (1) to improve access to health care, (2) to improve population health outcomes, and (3) to lower health care costs. The program stratifies all patients according to the severity of their condition using a Risk Stratification Model based on the University of Massachusetts Medical School methodology. The model scores patients on 26 categories (age, blood pressure, BMI, PHQ-9 score, etc.) and assigns them to one of three levels depending on the severity of their condition. In this way, the most appropriate and effective care can be delivered by multidisciplinary teams of health care professionals, including physicians, nurses, nutritionists, case managers, patient navigators, licensed therapists, community health workers, and many others. BHEP promotes disease prevention and management and utilizes evidence-based guidelines and best practices to fulfill Whittier’s mission of eliminating health disparities and their associated costs. The program places Whittier in the forefront of changing the health care delivery system from being expensive and episodic to being proactive, wellness- and prevention-focused, and more cost-effective.

3. What are your organization’s capabilities for doing this?

Whittier Street Health Center is recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 Patient-Centered Medical Home (PCMH). As a PCMH, Whittier delivers primary care that emphasizes care coordination and communication to enhance patients' experience with health care. Our delivery model is designed to lead to higher quality and lower costs by using physician-led multidisciplinary teams to address the whole health needs of the patient: medical, behavioral, dental, and social. Whittier also has a strong background in leading or participating in cross-sector collaborations to achieve health and wellness goals for the whole community. We work with public agencies and private companies to deliver a range of services to the residents of Boston's struggling neighborhoods. Through partnerships, we are able to reach vulnerable populations such as ex-offenders, new immigrants, refugees, chronically ill individuals, the elderly, students from low-income families, and others.

4. How will your organization know if you are making progress?

Whittier's Boston Health Equity Program began its first year of operation in 2012. It runs on a five-year schedule that aligns with the organization’s Strategic Five-Year Plan. BHEP has a “dashboard”—a comprehensive list of outcome measures that include cardiovascular health, mental health, metabolic and infectious disease management, prevention and screening rates, and other metrics. Data is recorded monthly on the BHEP Dashboard and compared against the 2012 baseline and the 2017 goals, which are based on national averages. Indicators include: 1) Community--Total enrolled patients; 2) Youth Patients--Youth with well-visit/physical, youth with BMI documented, youth with healthy BMI, obese/overweight youth with care plan, and youth with mental health screening; 3) Adult Patients--Adult with well-visit/physical, adult with BMI documented, adult with healthy BMI, obese/overweight adult with care plan, controlled hypertension, controlled diabetes, controlled depression, % breast cancer screening, % cervical cancer screening, % colon cancer screening, depression screening, HIV screening, Hepatitis C screening, diabetes screening, hypertension screening, HIV+ with controlled CD4, HIV+ with controlled viral load, and HIV+ with Hepatitis C screening; 4) Health System--Emergency room follow-up, hospitalization follow-up, race documentation, and ethnicity documentation.

5. What have and haven’t you accomplished so far?

We continue to see positive, statistically significant trends in preventive care using our Health Equity Program dashboard.
For screenings, we follow the recommendations of the US Preventive Services Task Force. As of November 2014, we have exceeded our goal for diabetic screening, with 72% of adult patients screened. We are also closer to our 59% goal of colon cancer screening with 51% of eligible patients screened.
Clinical results include 64% of diabetic patients with controlled diabetes (goal: 80%), 61% of hypertensive patients with controlled hypertension (goal: 80%), and 70% of HIV-positive patients with CD4 > 200 (goal: 90%).