Hear how Rosa Palacios, a CASHI Faculty Member and former consumer engagement advisor at Community Catalyst, ensures all voices are at the table and patients can take a leading role in any community health effort.

As a community-based housing organization that’s on the brink of change, Urban Edge has spent more than 20 years focused on acquiring and building affordable housing in the Boston area. Now, the organization is expanding into health and wellness – hoping to encourage and support residents in getting and staying healthy.

As the name implies, the Housing Well program combines two key elements of all of our lives – stable housing and balanced health. This program takes a two-fold approach 1) to inform residents about the organization’s health services and 2) educate the community development and real estate markets about the need to address health as a way to keep people housed and secure.

Urban Edge has made strides in partnering with other clinics and organizations to reach its goal. The organization has a referral program for its’ residents to the Dimock Center, a comprehensive community health center in the Roxbury neighborhood of Boston. Additionally, Urban Edge trains staff to become Community Health Workers to connect more easily to residents.

Gardening, a walking club, elder care, public safety, benefits screening, and financial coaching are a few of the services Urban Edge provides to residents. Part of what makes this program so successful is the support that it gets from residents who volunteer their time to keep the program going. With just seven staff working to keep residents connected to these services, the organization needs additional support. So it started a leadership development program that helps strengthen the resident volunteers’ leadership skills and provides professional development training.

As Urban Edge continues to grow, so do the communities it serves. With just under 3,000 residents now able to connect to the organization’s services, Urban Edge says it will continue to push the limits to break down silos, design around the community’s existing assets and show how bridging housing and other services with healthcare will remove barriers to good health.

In 2016, the idea of a “partnership” took on new meaning to Rogue Community Health and six other community organizations based out of Southern Oregon. In an effort to break down organizational silos, a group of seven CEOs started collaborating to rethink how they work together to better serve people in their community. Housing, food and childcare were just a few of the areas of focus.The decision, according to Chief Network Officer Ryan Bair, was based on the desire of the organizations to build closer relationships with each other and their patients.

“The group of CEOs met for about a year before the program was officially developed,” said Bair. “The meetings were about what the patients needed and the perspective was not – what can my organization get from this partnership – but how can we, as a team, provide the best services to people?”

Each of the organizations – Addictions Recovery Center, Southern Oregon Goodwill, The Family Nurturing Center, YMCA, Head Start and Access can screen and make referrals to a central hub. The shared case management software used by the team, allows for a confidential referral and makes it easier for the designated Community Health Worker to respond quickly to the referral. It means there’s an immediate and warm connection of the patient to the referred organization – providing comfort to patients while fostering open communication between organizations.

Organizational leaders still meet weekly to discuss the collaboration. They know quality improvement is vital to the success of the program. They hope to build-out a system for tracking population health disparities in Southern Oregon – a way to keep the momentum going and push their partnership to new heights.

Medical-legal partnerships transform care by integrating lawyers into the workflow of traditional medical clinics. Lawyers who are familiar with the impact of poverty on people’s lives can work with medical staff to address key barriers to care.

For Juliana Morgan-Trostle, the need was clear. Instead of forcing patients at West County Health Center with Contra Costa Health Services to go to an outside legal office for help, she brought the lawyers to them. Juliana first raised the idea to Bay Area Legal Aid during an internship in the San Francisco Bay area while in law school in New York City. Soon after, she got approval from the health center and received a two-year Equal Justice Works fellowship to provide services to Spanish-speaking patients who are survivors of interpersonal violence.

The program is the first in Contra Costa County to provide bilingual on-site legal services to medical patients. The partnership, says Juliana, makes it possible for many of the patients to get the help they need.

“Many immigrant survivors of interpersonal violence don’t seek out legal services due to a fear of being reported to immigration officials, a lack of transportation, or language barriers—yet many still do access healthcare services. Rather than falling through the cracks, this program helps survivors escape cycles of abuse.”

When the question came up about how the social services that go hand in hand with the legal services would be provided–there was a partnership in the works. Health Leads advocates, already at the clinic, would work with Juliana to make patient referrals and to complete the essential resource needs connections. Juliana would focus on offering free legal support for issues with immigration, family law, public benefits and housing.

Juliana is applying for long-term funding for the program. She has seen how health outcomes can be impacted by addressing the underlying issues that affect health. Now she’s hoping this medical-legal partnership will become a permanent way of caring for patients at the West County Health Center.

For over 50 years, Project Bread has led efforts to combat hunger in Massachusetts. The team is committed to this charge by helping people access healthy food today, and combating the systems that create hunger through advocacy, education, and community action.

The team at Project Bread acknowledges the role stigma associated with chronic hunger may play in stopping people from seeking help when they find themselves food insecure. Two of their initiatives, the Health Center Initiative and the FoodSource Hotline, highlight both the systems-change and direct service work done by the nonprofit.

With the Health Center Initiative, Project Bread partners with community health centers to combat hunger. Clinicians who understand that a person is food insecure connect them with the team at Project Bread, which follows up figure out the best resource or program for that person.

The FoodSource Hotline is a resource for anyone in Massachusetts who needs food assistance. Available in over 180 languages, the hotline guides individuals through SNAP (Supplemental Nutrition Assistance Program) screening eligibility, SNAP application assistance and connecting callers to local food resources in their community.

By partnering with communities and the different actors across the state that affect change — and understanding that food = health — Project Bread has made a difference for thousands of families and individuals throughout the state. We’re honored to partner with them to continue making a difference for communities across Massachusetts.