This story originally appeared on bwhbulletin.org

For much of her life, Yolaida Medina, 57, struggled to be healthy. At her heaviest, she weighed 297 pounds, and for years she had dangerously high blood pressure, a condition known as hypertension. She frequently got migraines, and her heart pounded furiously when she climbed the stairs to her third-floor apartment.

“My chest wanted to explode,” she said, recalling the sensation.

Medina faced barriers that made it difficult to prioritize her physical health. She sometimes didn’t have enough money to buy food and other necessities, and depending on public transportation for her medical appointments wasn’t always easy. For groceries, she tended to rely on her local corner store, which did not carry many nutritious options. And on the days when she was feeling overwhelmed, it became even harder to take care of herself.

Her high blood pressure was especially dangerous because she has a cerebral aneurysm — a weak spot in one of the brain’s arteries that could be deadly if it bursts. Hypertension significantly increases the chance of such a catastrophe occurring.

Today, life looks much different for the Roxbury grandmother. Her blood pressure is well-controlled, and she has lost more than 130 pounds. She started riding a bike, organized a local walking group, regularly sees a therapist, dabbles in gardening, shops for fresh produce and fish at the supermarket, and is in the process of qualifying for a first-floor apartment in her housing complex due to her medical needs. About a month ago, she quit smoking.

Medina says she was able to achieve these goals with the support of her primary care team at Brookside Community Health Center, who invited her in May to enroll in a three-month program to manage her blood pressure more easily, address health-related social needs and overcome barriers in accessing care.

As part of that effort, she was introduced to community health worker Franchesca Reynoso, who began visiting Medina at home, provided her a blood pressure cuff, showed her how to take readings by herself, helps track her progress and connects her with community resources.

The program is part of a larger strategy in Brigham Primary Care to address social determinants of health (SDoH), a term for nonmedical conditions that influence a person’s health, such as housing, education, employment and transportation access.

“It’s been a blessing. Everything is falling into place,” Medina said. “I tell my friends, ‘Go to the clinic and get an appointment with Franchesca. Ay, mami, she’s going to help you.’”

Data-Driven Interventions

Outcomes like this reflect the hard work and collaboration of several Brigham teams over nearly five years. The first SDoH screening pilot launched in 2018, and today all of the Brigham’s 15 primary care sites conduct this screening annually for every MassHealth patient. Four of those practices have expanded the screening to all primary care patients.

Eligible patients are asked questions like “Do you have trouble paying your heating or electricity bill?” and “What is your housing situation today?” About half of patients screen “positive” for at least one SDoH question, meaning their response indicates they might be facing a nonmedical issue that could affect their health. Food access is the most common concern; nearly half of patients disclose that they run out of food before they have money to buy more. One in three patients say they have housing needs.

“If you are facing a housing crisis and on the verge of being evicted, it’s going to be really hard to prioritize going to the doctor and monitoring your blood pressure every two weeks,” explained MaryCatherine Arbour, MD, MPH, medical director of the Social Care Team, a multidisciplinary group that seeks to address SDoH.

Consisting of community resource specialists, community health workers and housing advocates, the Social Care Team collaborates with clinical staff in Primary Care to help vulnerable patients navigate and access both health-related and community resources. In 2022 alone, more than 9,000 patients were referred to the Social Care Team for SDoH needs.

In February 2022, the team partnered with Population Health Management to analyze and interpret data from SDoH surveys alongside a trend they had observed in parallel: Black and Hispanic patients with hypertension were less likely to achieve blood pressure control than white and non-Hispanic patients with the disease.

After identifying the practices with the largest populations of Black and Hispanic patients — Brookside, Southern Jamaica Plain Community Health Center, 800 Huntington Ave. and the Phyllis Jen Center for Primary Care — the two teams developed a multipronged approach to reduce inequities in hypertension control, said Lisa Rotenstein, MD, MBA, medical director for Population Health.

In addition to the patient-facing components of the program, such as providing blood pressure cuffs and one-on-one community health worker support for eligible patients, staff also work behind the scenes to enhance care. Primary care providers, population health coordinators, pharmacists, community health workers and medical assistants regularly huddle to review individual patients’ cases and develop action plans. The Social Care Team is engaged if there is a patient who needs SDoH-related resources or support.

“By bringing population health data to the forefront, we can see vulnerabilities that can accompany poor hypertension control, such as having multiple co-morbidities, recent ED visits or difficulties engaging in care,” said Mary Merriam, RN, director of Population Health Management in the Center for Primary Care Excellence. “When we have the full landscape, we can zero in on the right interventions and identify patients who might benefit from working with the Social Care Team.”

Since the hypertension program’s launch last year, the teams report they have closed the gap in blood pressure control between Hispanic and non-Hispanic patients. Although rates have improved among Black patients, a disparity persists that the teams continue working to remedy.

Recognition of such inequities helped shape Mass General Brigham’s new strategy, For Every Patient, which articulates that all of MGB’s academic medical centers, community hospitals and clinical care sites will work together as one system to elevate the quality of care in ways that are proven to make the biggest difference. This includes achieving equity in blood pressure control, substance use overdose, C-sections for low-risk pregnancies and colorectal cancer screening and treatment.

‘You’ve Got This Aura’

Since enrolling in the program, Medina doesn’t worry about not being able to afford groceries. If her monthly food assistance gets used up too soon, she informs Reynoso, who brings her a supermarket gift card to bridge the gap before her benefits replenish. Every morning, Medina also receives a home visit from a nurse — a routine that immediately demonstrated its necessity after the nurse observed Medina was taking her blood pressure medication incorrectly and then educated her on the best way to take it.

Reynoso also stops by regularly to collect her vital signs, including her blood pressure, and enter them into Epic so that Medina’s primary care provider can stay updated. But her role is more than clinical. She was the one who helped Medina navigate the complexities of applying for a housing transfer. They sometimes go for a walk together. Often, she just listens as Medina catches her up on the latest happenings in her life.

“I really enjoy going above and beyond for my patients to get them what they need. It fills me up and gives me strength,” Reynoso said. “I think the patients really enjoy having us meet them at home, too. It creates a real connection and shows that we care — that they’re not just a number.”

Reflecting on the bond they have built, Medina affectionately put her arm around Reynoso.

“I just love her,” Medina said. “As soon as Franchesca came to my house for the first time, I just started telling her everything about my life. She consoled me, comforted me and laughed with me. I told her, ‘You’ve got this aura.’ I feel so comfortable with her.”