Duffy Impact: 2022

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Duffy Impact: Fiscal Year 2022

Dear Friends,

As we approach the end of this milestone year, we acknowledge that we have entered a new era of providing health care that has been deeply impacted by the COVID pandemic. The pace of change has accelerated, from the way we provide care to the way we are compensated for services; sometimes it feels like a tidal wave is sweeping us toward the future.

To ensure Duffy Health Center’s ability to effectively serve the most marginalized members of our community for another 25 years (and beyond!), over the course of the past year we’ve looked inward. We’ve taken the time to strengthen our systems - and implement change where needed - so that we’re poised to move to the next phase of our strategic plan. This internal work will continue in the upcoming year, and will be a foundational element in support of the value-based payment model that will define health care delivery for low-income patients in Massachusetts for the next five years.

Our strategic goals for the upcoming year include:

• Aligning our resources to sustain operations, which includes further integration of our care teams as we move toward value-based payment, a care model that incentivizes quality over quantity;

• Implementing new tools for effective patient engagement, notably the conversion to a new electronic health record and optimizing telehealth; and

• Responding to gaps in community needs, including recovery support services and our In From the Streets program for medical respite and cold weather sheltering.

The Duffy team’s professionalism, dedication to our patients, and commitment to our mission are what have carried the organization to success through the past 25 years. We are highly confident in our team’s ability to shift with the upcoming tide of change and continue providing the highest quality of equitable, integrated health care, and support services to our vulnerable and marginalized neighbors.

We are grateful to you, who understand the importance of our mission and continue to generously support our work.

Thank you!

Duffy Health Center

Kathleen Bresette President, Board of Directors Duffy Health Center

Heidi Kathleen Bresette, President Susan Harrington, Vice President John Murphy, Treasurer Paulette Shaw Querner, Clerk James J. Cullen Miguel R. DaSilva Jeffrey Haddad Christine Johnson-Staub Chester H. Mohr, MD Stuart Murphy Vanessa Proc Kurt E. Raber Mary Rahal Olympia Ramos Peter Scarafile Richard N. Smillie Corrie Vilsaint, Ph.D. Honorary Members: Dr. Hub Mathewson Dr. Neil Ringler Andrew Singer, Esq. Duffy Health Center Fiscal Year 2022 Board of Directors

Community Health Focus: Blood Pressure Management

This year, Denies Smith-Grant began working at Duffy Health Center as a Medical Community Health Worker (CHW) with Duffy’s medical team. The CHW role is defined by the American Public Health Association as “a frontline public health worker who is a trusted member and/or has an unusually close understanding of the community served.” (Source: apha.org)

The Medical CHW role falls under the supervision of Duffy’s Quality Improvement Manager, because the team works together to address chronic diseases impacting our patient population. In her first months at Duffy Health Center, one of Denies’s focus areas has been on assisting identified patients to bring their high blood pressure, or hypertension, under control.

The program is structured as follows:

• Providers refer patients with high blood pressure to Denies as the Medical CHW. Denies also conducts research in the electronic medical record to identify patients who are eligible and could use additional support. The program is optional; patients show an interest in monitoring their hypertension at home.

• The Medical CHW conducts an intake visit, reviewing patients’ medical needs and addressing potential

barriers to participation in the program.

• Denies provides weekly follow up via telehealth for at least 4 sessions, depending on patient needs. She reviews a structured and flexible curriculum on lifestyle topics with the goal of educating patients to use food as medicine.

• Blood pressure cuffs are provided to patients for athome monitoring, and they report their readings to the Medical CHW.

Of the 2,532 patients who received medical services in FY2022, 735 (29.03%) had a diagnosis of hypertension At the end of FY2022, the rate of Controlled Hypertension for Duffy patients was 56.87%. Our goal is 60%. The average for Massachusetts Community Health Centers like ours is 54.86%.

The goal of the program is to improve access to care and ultimately improve patients’ blood pressure control. The role of the Medical CHW is a key element to the success of the program given the one-on-one peer support she provides.

“I am there to educate and provide peer support,” shares Denies. “Some patients have gotten to a point where they touch base with me and can talk through what happened that week that caused their level to go up or down. We just take baby steps, and I help them as they go. I support them with other needs, like filling out paperwork or referring them to other people in the agency who can help with meeting their needs.”

Metric Goal 1st Measurement (7/5/2022)) Case load (# currently engaged in program) 20 patients 11 patients Enrollment Rate (# attended initial appt + BP machine/ # enrolled) N/A 80% (12/15) Appointment Attendance Rate (# scheduled appt/ # occurred) 60% 69.23% (45/65) Rate who opt for lifestyle education (# who opt/ # total attended initial appt + BP machine) 50% 100% (15/15) Percent reduction in blood pressure after 4 sessions 20% 40%

Providing Meaningful Care: Reproductive Health

“Reproductive health care is often overlooked in the broader look at health. Having the ability to control reproduction is essential for all women, but is particularly important for women who may be struggling with poverty. At Duffy Health Center, having a specialist on site validates the issues that women face,” says Dr. Lisa Jones, MD, FACOG, CPE, Chief Medical Officer at Duffy Health Center.

When Dr. Jones joined the Duffy team in September 2021, it marked the first time we’ve had a provider specifically qualified to provide reproductive health care services. Prior to her arrival, our primary care providers were able to practice varying levels of basic gynecological care depending on their training. There was no provider qualified to insert long-acting reversible contraceptives or perform many gynecological tasks; these were handled through outside referrals, adding a level of complication for our patients.

The addition of gynecological care at Duffy Health Center

has increased care integration, providing our patients - who have built trusting relationships with members of our team - with the option to receive this specialized care in a place where they already feel safe. Many of our patients have a history of sexual trauma that can make this type of visit very scary, especially if it occurs in a new environment and potentially re-traumatizating if they have to reshare their history.

In FY22, 20% of biologically female patients had a Women’s Health provider visitup from just 7% the previous year.

At Duffy, some patients will have their therapist or recovery support navigator accompany them in the exam room for an added level of support, so they may have these sensitive conversations with people they trust. A particularly important aspect of the gynecological care provided at Duffy is family planning. Depending on individual patient needs, Dr. Jones advises on contraception as well as pre-conception and pre-natal care. As a Federally Qualified Health Center, Duffy has always been prohibited from providing abortion access to patients. We know, however, that reduced access to contraception will disporportionately affect low income and marginalized patients, the exact population we serve. This makes the reproductive health services we are able to provide more important than ever.

Gender-Affirming Care

In addition to gynecological services for women, Duffy Health Center provides gender-affirming care for transgender people. Providing this valuable service to transgender patients is extremely important. A lack of appropriate transgender care puts individuals at higher risk for depression and substance use disorder. By taking a broader overall health perspective with the provision of gender-affirming hormone therapy, we are able to reduce the risk of behavioral health and substance use disorders.

Eryn Tomascik, a Care Coordinator at Duffy Health Center who is transgender herself, shares, “I have several clients who are excited about having access to hormone therapy at Duffy. The biggest contributing

factor is locality, not having to drive all the way to Boston for treatment. Having a Primary Care Provider that provides gender-affirming care locally is a welcome relief, especially considering not only the cost of gas and public transit, but also knowing that your local community truly does care its about LGBTQIA+ population.”

Offering this care at Duffy Health Center makes access easier, giving patients the option of having all their care under one roof, in a space they know is safe. It reduces stigma when transgender care is integrated with primary care. While a small percentage of Duffy patients currently access these services (10-15 individuals), this type of access to care makes an immeasurable difference in their lives.

Quality Measure Duffy Target 2022 Q2 2022 Score Pregnancy Intention Screening 80% 78.89% Contraceptive Counseling 80% 80.90%
3,060 Patients Served 5,627 14,108 3,416 636 4,429 11,007 5,423 8,307 2,700
utilization rate for our services, as illustrated
have a higher-than-average

25 Years of Trust & Impact

“My support system, my network started here. I wouldn’t be where I am today if it wasn’t for this awesome team. I walked in here hopeless... you guys saved my life.”

- Nina, Duffy patient

“Everyone at Duffy worked with me until I was back up and running... they went 100% all the way with me. Duffy is all I know. It’s everything to me. It’s my life. Duffy is a wonderful place to regain yourself.

- Lonnie, Duffy patient

“I feel like a person again...I basically tear up every time I’m there because Duffy Health Center is how health care should be for everyone; everyone should be treated with kindness and dignity.”

– Brittany, Duffy patient

“I have a lot of trust in this place. People here treat you with respect no matter who you are. They show that you can trust them. When you see that, you’re more likely to go back.”

- Jeff, Duffy patient & board member

“When I come here, they know my name - that's more than you can imagine. You are a person. That's what's so special about this place.”

- Richard, Duffy patient

“I’m really proud of what I’ve done, and I’m really proud of the help that I got at Duffy. I’m proud and I’m happy... and grateful for what they’ve all done for me. I can’t say ‘thank you’ enough.”

- Vanessa, Duffy patient & board member

Looking Forward: Exceptional Integrated Care

As the health care landscape evolves, community health centers like Duffy remain on the front lines of change. As we approach the upcoming year, we have set goals that are in-line with our strategic priorities and set the stage for the agency to be prepared for success in the future of health care.

Conversion to Epic Electronic Health Record

Joining other community health centers and larger health systems on the most commonly-used electronic health record will improve care coordination both internally and externally. It will allow for more efficient and effective communication.

Transition to Value-Based Payment

Increased communication = increased quality Improved care coordination, externally & internally

Care Integration & Quality Improvement

The transition to Value-Based Payment means that Duffy Health Center will be paid for the quality, rather than the quantity, of care provided to patients. The payment model incentivizes the integrated, trauma-informed care model that Duffy has practiced since its earliest days.

Improved quality & reduced cost to the health care system

Space Changes at Duffy

A reorganization of the physical arrangement of Duffy’s internal teams will allow multi-disciplinary care teams to work more effectively together by improving real-time accessibility to colleagues across disciplines.


Fiscal Year 2022

Net Patient Service Revenue 3,664,230 Grant Revenue 4,619,113 Program Revenue 183,185 Donations & Special Events 305,266 Other Income 1,963,173 TOTAL 10,734,967

Fiscal Year 2021

Net Patient Service Revenue 3,487,625 Grant Revenue 5,176,922 Program Revenue 232,582 Donations & Special Events 292,964 Other Income 1,266,566

TOTAL 10,456,6599

Net Patient Service Revenue Grant Revenue Program Revenue Donations & Special Events Other Income

Net Patient Service Revenue Grant Revenue Program Revenue Donations & Special Events Other Income

4,619,113 183,185 305,266 1,963,173 FY 2022 Revenue Actual
3,547,515 5,176,922
232,582 292,964
FY 2021 Revenue Actual


Fiscal Year 2022

Salaries and Wages 6,050,487 Taxes and Fringe 1,409,248 Contracted Services 180,193 Occupancy 660,968 Client Expenses 865,138 Supplies & Minor Equipment 142,296 Office Expense 92,546 Bad Debt 119,991 Depreciation Expense 226,201 Other Expenses 752,785

TOTAL 10,499,853

142,296 92,546 119,991 226,201

752,785 FY 2022

Expense Actual



6,050,487 1,409,248 180,193

Salaries and Wages Taxes and Fringe Contracted Services Occupancy Client Expenses Supplies & Minor Equipment Office Expense Bad Debt Depreciation Expense Other Expenses

Fiscal Year


Salaries and Wages 5,530,542 Taxes and Fringe 1,290,980 Contracted Services 405,567 Occupancy 510,378 Client Expenses 271,663 Supplies & Minor Equipment 122,299 Office Expense 70,798 Bad Debt 96,081 Depreciation Expense 207,237 Other Expenses 737,996

TOTAL 9,243,541

510,378 271,663 122,299 70,798 96,081 207,237 737,996


FY 2021 Expense Actual

5,530,542 1,290,980

Salaries and Wages Taxes and Fringe Contracted Services Occupancy Client Expenses Supplies & Minor Equipment Office Expense Bad Debt Depreciation Expense Other Expenses

Thank you for making our work possible.

Ms. Jennifer Allard

AmazonSmile Foundation

Mr. and Mrs. Ross Anderson

Ms. Lois Andre and Mr. Earl Springer Anonymous

Ms. Abigail Archer* B Free Coaching & Wellness

Dr. and Mrs. Albert A. Barrows, III Ms. Julia Bateman*

Belonging to Each Other Mr. Keith Benoit

Joan Bentinck-Smith Charitable Foundation

Ms. Mary Bianchini and Ms. Kathleen Rioux* Reverend Connie Bickford* Mrs. Doreen Bilezikian

The Blackbaud Giving Fund Ms. Jennifer Blair

Dr. and Mrs. J. Bonnet-Eymard Mr. and Mrs. Greg Botsivales Ms. Carrol Bradley

Ms. Kathleen Bresette* Mr. Mark Bresnahan Mr. and Mrs. Dennis Briand Ms. Stephanie Briody Ms. Pamela Brown Mr. James Buffington Dr. Donna M. Buonopane and Dr. Bart L. Main Dr. and Mrs. Loren C. Burger Ms. Emily Burke Mr. Cliff Calderwood Ms. Janice Campbell

Cape Associates, Inc. Cape Cod Cooperative Extension Cape Cod Council of Churches

Mr. Michael Carney

Ms. Carolyn Carpinella

Mrs. Sylvia Carter

Ms. Lorraine Casey

Mr. Robert F. Casey and Ms. M. Virginia Waterman-Casey

Castle Point Management, Inc. Catholic Social Services of Fall River Ms. Patricia Cawley

Ms. Frances Charis

Ms. Patricia Charon Ms. Catherine Childs Mr. and Mrs. Frederic Churchill Mr. and Mrs. Robert Churchill, Jr. Mr. Peter Clark Ms. Eleanor Claus Mr. John Clinton Mr. Richard Cohan Dr. Melvin Cohen and Ms. Pamela Smith Ms. Lucia Colla Mr. George Comeaux ConServ Group

Mr. and Mrs. Paul Cormier Mr. and Mrs. Grant Cornell Ms. Jane Costello Cove Acre

Ms. Jane Cronin Ms. Samantha Cronin Ms. Maura Crowley Ms. Natalie Culgin Mr. and Mrs. James J. Cullen Ms. Dolores E. Daluz Ms. Karen Danskin Mr. Miguel R. DaSilva and Ms. Maria Ribeiro Ms. Elizabeth Dawes Ms. Jean Dawson and Ms. Stacey Knox Ms. Kathleen DeFeo Dennis Union Church Dr. Charles Diana and Ms. Elizabeth Brice Dr. and Mrs. Louis Di Lillo Ms. Kathryn Dienst Mr. Peter Dikeman Mr. and Mrs. Neil Dolan* Mr. and Mrs. Jim Donnelly* The Robert J. Donohoe Trust Mr. and Mrs. Joseph Doolin Ms. Jane Driscoll Mr. and Mrs. Michael Driscoll* Mr. and Mrs. Leonard Duchesney Duffy Properties Ms. Barbara Duffy Ms. C. Pamela Duffy Ms. Katherine Natalie Duffy Mr. and Mrs. Robert Duffy, Jr.

Mr. and Mrs. Paul Duplessis

Ms. Dionne Dupuis

Eastern Bank Foundation East Main Street Development, LLC East Shore Safety, LLC

EBI Consulting

Dr. William H. Ellis and Dr. Stefanie M. Adams Encore of Falmouth Newcomers

Ms. Mary Jane Farley Mr. Larry Feidelseit

Dr. and Mrs. William N. Fenney Ms. Margaret Flanagan Foley & Foley, PC

Mr. Gary Forester

Dr. and Mrs. Frank Fortunato Mr. and Mrs. William Foster

Mr. Mark Franklin, Cove Acre

The Sean M. Gannon Memorial Fund of the Cape Cod Foundation

Ms. Alicia Gapstur*

Mr. Rolf Gates

Ms. Deborah Gavron

Mrs. Margaret Gaylord

Ms. Donna Geheb

Ms. Elizabeth Gibbs Ms. Joanne Giganti

Ms. Rachel Gillis Ms. Martha Gilmore

Ms. Cynthia Glista

Mr. and Mrs. Paul C. Glynn Mr. Matthew Goode Ms. Claire Goyer* Ms. Sara Grambach* Mr. Greg Grandmont

Mr. John Greene and Ms. Jane Walsh Ms. Suzan Greenup

Dr. and Mrs. Donald Guadagnoli Mr. Henrik Gulmann

Mr. John Haas

Mr. David Hale

Mr. David Halvorsen

Ms. Chris Hardy*

Ms. Susan Harrington

Ms. Susan E. Harrington

Ms. Kathryn Harris

Mr. Cody Henderson

Ms. Paula Hersey*

Ms. Mary Hettich-Kelly

The High Pointe Foundation Mr. and Mrs. Hugh C. Hilliard

Mr. James Hinkle and Mr. Roy Hammer Ms. Regina Hopkins Mr. Matthew Huberman Ms. Maureen Hughes Ms. Lisa Jason Ms. Christine Johnson-Staub Dr. Lisa Jones

Susan P. Jones Family Foundation Dr. H. Walter Kaess Mr. Randy Kammer Ms. Cathy Kautz Mr. David Kendziorski Ms. Vicki Kennelly* Ms. Lisa King Mr. and Mrs. Roger Kligler Mrs. Colleen LaBelle Ms. Martha Lagoy Taylor Mr. William Lamont Mr. and Mrs. James A. Lane Ms. Brenna Lapsley Mrs. Sarah Lapsley-Martin Ms. Lisa Laramee Ms. Stephanie LaRoche Mr. Thomas R. Lebach Ms. Irene Lehan Ms. Kate Lena Lightship Dental, Inc. Mr. and Mrs. Raymond Loranger Love Live Local Dr. and Mrs. David R. Lovett

Lyndon Paul Lorusso Charitable Foundation Mr. and Mrs. Robert Maloney Ms. Lucille Marcigliano Mrs. Anna Marini* Mr. Dennis Mascio

Massachusetts League of Community Health Centers Dr. Herbert Mathewson Ms. Amanda McGerigle* Mr. and Mrs. David McGraw Ms. Patricia Mcguirl Ms. Carol McManus Ms. Suzanne Methelis Mr. and Mrs. Peter Meyer Ms. Lida Miner Dr. and Mrs. Chester H. Mohr Ms. Carolina Monroy

Mr. and Mrs. Mullaly-Sweeney

Mr. and Mrs. John E. Murphy

Mr. Stuart Murphy

Murray & MacDonald Insurance

Ms. Kim Neidermire*

Mr. and Mrs. P. Gordon Nelson

Mrs. Heidi Nelson*

Jean Nichols Charitable Trust Mr. Mark Nickels

Northside United Methodist Church

Nove Yoga and Wellness

Ms. Judith November

Ms. Ellen O’Dell

Ms. Pamela Thoits Olson

Ms. Charlee O’Neill

Mr. and Mrs. David I. Oppenheim

Ms. Colleen Ormsby

Mr. and Mrs. Brechner Owens

Ms. Taylor Parmenter

Mr. and Mrs. Gary Pastva

Ms. Lauren Payne and Mr. Bill Swanson

Mr. and Mrs. John Pendergast

Ms. Lisa Perkins*

Dr. Thomas Philbrick

Ms. Nicole Poillucci

Mrs. Mary Police Mr. and Mrs. Dean Potter

Mr. and Mrs. Ronald S. Pritzker

Provincetown United Methodist Church Ms. Janet Purrier-Lewis

Mr. Kurt Raber*

Dr. Rosa Ramirez Mendez* Dr. Seppo Rapo

Ready Rooter, Inc. Ms. Joyce Reardon Dr. Judy Recknagel

Ms. Shelley Redstone

The Mary and Redwood Wright Fund of The Cape Cod Foundation

Mr. Douglas Reynolds

Ms. Abigail Rhoads

Mr. Wesley Richardson

Dr. and Mrs. Neil Ringler

The ROAR Fund of the Cape Cod Foundation

Ms. Christine Roscoe

Mr. Don Royer, East Shore Safety, LLC

Mr. and Mrs. Paul J. Ruchinskas

Ms. Dorothy Savarese

Mr. and Mrs. Peter Scarafile Ms. Paula Schnepp

Ms. Paulette Shaw Querner

Dr. and Mrs. David Sheinkopf Simple Generosity Law Office of Singer & Singer, LLC Mr. and Mrs. Terrence Slack Mr. Mike Smith

Mr. and Mrs. Lawrence Spaulding The Stand

Star Market Give Back Where It Counts Bag Program

Ms. Mary Catherine Starr Ms. Lynn Stevens Ms. Pamela Stiefvater Mr. Kurt Stiffel St. David’s Episcopal Church St. Mary’s Episcopal Church Mr. Raymond Sullivan, Jr. Sunderland Printing TD Bank Team M25

Joseph W. and Faith K. Tiberio Charitable Foundation Mrs. Janet Totten Dr. and Mrs. Gary E. Tratt Ms. Harriet Traub Ms. Gail Turner and Mr. Peter Spier Mrs. Frederica Valois Ms. Evelyn Van Norman Dr. Corrie Vilsaint* Mr. David Vinal*

The Arend W. D. and Sheryl Vos Charitable Fund Ms. Erica Waasdorp Ms. Terry Shea Walsh Mrs. Ellen Wendell Wendy’s Mr. Eric Williams Ms. Christina Wiseman*

The Winsor Foundation Fund at the Boston Foundation Ms. Moira Kate Woods Mr. and Mrs. Ted Wurzburg* Ms. Maureen Yachimski Mrs. Linda Zammer Mr. Clement Zielinski

* Donors who are members of Duffy’s Community of Hope, our monthly giving program.

If you’d like to make a gift to Duffy Health Center, click here.

Thank you.

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