Building Vibrant Communities

This program was established as the result of an intensive nine month long assessment and planning process conducted in five targeted Boston Public Housing Developments. The assessment identified a high prevalence of chronic disease among residents including hypertension, diabetes, asthma and depression. Unemployment, neighborhood violence, and difficulty accessing a doctor were consistently identified by residents as major barriers to remaining healthy.

Model – Social Health Coordinators, who are residents of the housing developments, were trained and connected our target population to health and social services intended to improve health outcomes and reduce disparities.

 Our Partners Include:

• Boston Housing Authority
• Somali Development Center
• The Eritrean Society
• Boston Public Health Commission
• Public Housing Tenant Task Force
• YMCA Roxbury
• Bay State Physical Therapy
• Dana-Farber Community Based Participatory Research
• Fresh Truck
• The Kresge Foundation which generously funded a multi-year grant to initiate this program

 Our Team

• Project Lead – Director of Wellness Initiatives
• Social Health Coordinators
• Registered Dietician/Nutritionist
• Life Coach/Community Health Clinician
• Physical Activity Specialist
• Youth Violence and Prevention Team
• Community Stakeholders/Partners
• Local Evaluation Team – Quality Assurance Department

 Program activities include:

• Referral and Care Coordination Services
• Six- to eight-week Wellness Groups
• Nutrition education and cooking demonstrations
• Physical activity sessions
• Violence prevention sessions
• Health and lifestyle coaching
• Job Readiness

 Monitoring & Evaluation

• An online database tool, Redcap captured quantitative data.
• Over 1,000 members were engaged and/or participated in at least one of the 6 group activities. (2011 – 2014)
• Health Screening
• Social and Health Service Referrals
• Nutrition and overall health assessment
• Community Connectedness assessment
• Depression, Anxiety and Stress Scales analysis (DASS)
• Clinical outcomes tracking
• Key Informant Interview Report (External Evaluators)
• Focus groups and qualitative analysis

 What We Have Learned:

• Social Health Coordinators (Patient Navigators) play a significant role in reducing social and health disparities.
• Improving access to mental and clinical services can greatly improve community health.
• Education and demonstration activities for community members improve clinical and social outcomes.
• Community Partnerships are a critical component to the success of any wide-scale intervention.
• Regular stakeholders’ and program participant feedback helps ensure long-term success and sustainability.
• Group physical activities help increase community connectedness.
• Social disparities/inequalities have a direct impact on clinical outcomes.