” Advocating Success for Kids (ASK) – JMSCHC continues to collaborate with Children’s Hospital to help kids between the ages of 3-9 who are having learning or behavioral problems in school or at home by providing free behavior risk assessment and counseling services to these at-risk school children. The team consists of the child’s doctor, an educational specialist, a psychologist, a developmental pediatrician and a case manager. The case manager helps parents and schools complete recommendations, coordinates the services across the involved families, schools, and service providers, and improves tracking of results.

” Cardiovascular Disease – JMSCHC addresses the prevention and treatment of cardiovascular disease through visits with the primary care provider and programs that serve specific subpopulations. The nutritionists and case managers for the “Live and Learn” diabetes program and the Women’s Health Network (WHN) Program educate their patients about cardiovascular risks and prevention via lifestyle modifications. A total of 700 women were screened through WHN in FY06. In addition, outreach staff conduct community health screenings for diabetes, cholesterol levels, and blood pressure levels and refer at-patients to health center providers as appropriate.

” Centering Pregnancy – The Health Center, in partnership with Mount Auburn Hospital, offers a Centering Pregnancy Program to its prenatal patients. Centering provides prenatal care in a group model where women receive basic prenatal assessment, share informally with other women, and discuss together content related to childbearing and parenting. Key objectives of the program include increasing the number of immigrant women who receive prenatal care and social support services (WIC, insurance, etc.); increasing the use of preventive care among the women and their families; demonstrating a sustainable model to deliver cost-effective and culturally competent prenatal and postpartum care; and creating support networks among pregnant immigrant women. In FY06, approximately 50 patients participated in Centering classes.

” Early Breast and Cervical Cancer Detection – This Women’s Health Network (WHN) program provides complete physical exams, including breast exams and Pap smears, education regarding self-breast exams and the importance of yearly Pap smears, and mammograms to low-income, uninsured women 40 to 64 years of age and women younger than 40 if they have a family history of breast or ovarian cancer. To ensure timely, appropriate follow up, any woman with an abnormal mammogram, breast exam, or Pap smear is placed into case management. Patients ultimately diagnosed with cancer are referred to low-cost or free treatment programs. Approximately two-thirds of the women in the program receive their mammograms at JMSCHC on the Dana Farber Boston Mammography Van. A total of 910 low-income women received assistance through WHN in FY06.

” Early Intervention Screenings – In collaboration with Thom Charles River Child and Family Services, the program provides on-site early intervention initial assessments to Waltham patients upon referral from JMSCHC primary care providers regarding possible delays. Thom Charles River will provide follow-up EI care at the patients’ homes as appropriate.

” Massachusetts Health Disparities Collaborative (HDC) for Treatment of Diabetic Disease – This program, offered in collaboration with the Joslin Clinic and Beth Israel Deaconess Medical Center, provides comprehensive, culturally appropriate ongoing diabetes case management and specialist services to over 65 patients diagnosed with diabetes who are willing to undertake chronic disease self-management. An additional 200 patients in the “Live and Learn” diabetes program also benefit from HDC protocols. The Health Center’s case manager monitors health data, provides one-on-one health education and lifestyle counseling, ensures compliance with vision and podiatry screening requirements, arranges on-site nutrition and endocrinologist services, and inputs compliance and test results so data is available at all primary care visits.

” Medication Case Management – JMSCHC addresses patient need for improved access to low-cost and/or free medications and support for compliance with medication dosing regimens and monitoring of potential adverse effects by offering regular clinical medication management sessions. During these visits, JMSCHC staff assist patients with completing initial patient applications for medication assistance, as well as renewals, based on pharmaceutical company requirements. Staff also patient assistance program applications, provide health education on a patient’s chronic conditions, and review and discuss relevant clinical measures and laboratory results. Over 90 patients are assisted with accessing medications each month.

” Prenatal Education -- The Mom-to-Mom Program matches 36 pregnant immigrants bearing their first child in the United States with a mentor from their own cultural background. The goal of this program is to provide emotional support to expectant mothers during this important phase in their lives, facilitate access to Health Center and hospital services, acquaint patients with American hospital and delivery procedures, provide information on medical insurance, and insure that regular prenatal, newborn and post-partum visits occur.

” Tuberculosis Management -- JMSCHC continues its association with the Boston Public Health Commission’s Tuberculosis Control Program. In this program, all pregnant patients and at-risk adult patients are tested for tuberculosis at JMSCHC. Those who test positive are referred to the Boston Medical Center for evaluation and formulation of a treatment plan, after which they return to JMSCHC, where they receive medications free of charge and are monitored monthly for complications of treatment. Currently over 200 patients are receiving tuberculosis case management services.