Duffy Health Center 2022

Restoring Health.

Rebuilding Lives.

Table of Contents I.

Duffy at a Glance An overview of Duffy Health Center

II.

Duffy Patient Brochure An overview of our patient-centered model of care

III.

Strategic Plan: Fiscal Years 2022-2024 A summary of Duffy’s current Strategic Plan and priorities for FY22

IV. Duffy Doings: Fall 2021 Duffy Health Center’s bi-annual newsletter V.

2021 Impact Report Clinical and program highlights from Fiscal Year 2021

Throughout calendar year 2022, we are celebrating the 25th anniversary of Duffy Health Center’s incorporation as a nonprofit in the state of Massachusetts. What a milestone!

Our success over the past 25 years is due in large part to the trusting relationships we’ve built: with individual stakeholders throughout our community, who have a vested interest in caring for the most vulnerable among us; with our partner agencies, who bring their own expertise to support our patients’ complex needs; with our staff, whose service to our mission and commitment to our work is second-to-none; and most importantly, with the individuals who have entrusted us with their care.

Time and again, we hear about the positive impact Duffy has had in the lives of the individuals we serve. Without fail, that impact can be traced directly back to the trusting relationships our team has built with some of our most marginalized, most vulnerable neighbors, and the ways that we provide support inside and outside of the walls of our building at 94 Main Street.

As we embark on this landmark year, we know that now more than ever, the innovation, strength, and passion our team brings to this critical work is vital to the health of our greater community.

In 2021 we worked through a months-long process to create our Strategic Plan for fiscal years 2022 through 2024 (more details enclosed). Our primary goals for this year include: • Positioning ourselves to expand our models to provide additional care coordination, case management, and substance use disorder support services as our team’s expertise continues to be sought by community partners.

• Expanding staffing and service delivery within our Behavioral Health department to meet the increased demand for mental health services.

• Improving internal workflows and processes, specifically the optimizations of telehealth and effective use of our space.

In addition to these important organizational goals, we plan to spend some time celebrating all that Duffy Health Center has accomplished over the past 25 years! Throughout the year, we will be sharing communications with the broader community that celebrate our past and look toward our future. Fun facts about our work and our history will be shared via email, postcard, social media, podcast - you name it. Our 25th anniversary will also be celebrated through events, including our Wellness on the Water series; small, exclusive events with the monthly donors in our Community of Hope; our team’s second run in the Falmouth Road Race this August; and a large, festive event with our community to culminate celebrations in November.

We are grateful for your support and look forward to partnering with you throughout this exciting year.

Sincerely,

Heidi R. Nelson, FACHE CEO, Duffy Health Center

At a Glance The mission of Duffy Health Center is to provide equitable, integrated primary health care and support services to persons who are experiencing homelessness or at risk of homelessness on Cape Cod, and to improve the quality of life for vulnerable and marginalized populations through community collaborations, leadership, and advocacy.

Revenue Budget FY21: $10,300,000 Full-Time Employees: 90 Medical Providers: 7

Psychiatric Providers: 2

Behavioral Health Therapists: 8

Sites: 94 Main Street, Hyannis St. Joseph’s House, Hyannis Outreach Sites:

Barnstable County Correctional Facility Gus Canty Community Center (Falmouth) Pleasant Bay Community Boating (Harwich)

Programs and Services Medical Care Primary and preventive care • Referrals to specialists • Nutritional education and counseling • Chronic disease management • Hepatitis C and HIV treatment and prevention • Chiropractic services • Shared medical appointments • Care coordination • Women’s health Behavioral Health Assessment, evaluation and treatment • Psychiatric services • Medication management • Individual and group counseling • Spiritual care • Support for LGBTQ+ Substance Use Treatment Assessment and treatment • Relapse and recovery outreach and peer support • Medication assisted treatment paired with counseling • Programs for teens, young adults, and pregnant and parenting women Case Management Assessment, support and advocacy • Assistance with daily needs: food, shelter, showers • Health insurance benefits assistance • Connection to community services • Housing referrals and placement • Homelessness prevention • Homeless outreach • Emergency shelter program 94 Main Street, Hyannis MA 02601 • DuffyHealthCenter.org

2021 Patient Demographics Age of Patients

60% of our patients live on an income of less than $14,000 per year; below 100% of the federal poverty level.

18-24

Living Conditions for Patients Identified as Homeless 80%

5%

9%

24%

33%

72%

25-39 40-54

70%

55-64

60%

65+

50% 40% 30%

28%

20% 5%

7%

Homeless Shelter

Transitional Housing

10% 0%

8%

4% Doubled Up

Street Homeless

Permanent Supportive Housing

5%

Insurance

Other

Of the 3,060 patients served in 2021, 2,566 (84%) were experiencing homelessness, as defined by federal guidelines.

The majority (72%) were living in “doubled-up” conditions - staying with others.

9%

9%

Uninsured

24%

Medicaid Medicare Other insurance 58%

PATIENTS/CLIENTS

2019

2020

2021

Medical Behavioral Health Case Management Total

2,803 1,338 1,701 3,319

2,429 1,194 925 2,863*

2,521 1,214 1,424 3,060

VISITS

2019

2020

2021

Medical 16,183 15,790 13,856 Behavioral Health 8,918 10,998 10,510 Case Management 5,481 2,327 3,527 Total 30,582 29,115 27,893

On average, individuals in our care are in contact with the members of their care team 9 times per year. Most patients access more than one of our services.

• Medical patients averaged 5 visits per individual served.

• Behavioral Health clients averaged 9 visits per individual served.

• Case Management clients averaged 2 visits per individual served.

*Although visits were stable in 2020, the number of patients served decreased due to the pandemic.

Strategic Goals Getting the “Duffy House” in Order: Resource alignment to sustain operations; New tools for effective patient engagement Expanding Our Programs & Our Reach: New programs to respond to Duffy patient needs; New populations to expand our impact Responding to Community Needs: Addressing gaps in community services Developing Our Workforce: Diversity, safety, and continuous quality improvement

Our Services

What a

Providing Exceptional

Patient-Centered Integrated Care

patient-centered medical home means to you…

Welcome to Duffy, a community health center that meets your needs.

Care with dignity and respect.

Good health is key to a good life. Feeling safe and supported will help you reach your goals.

Staff at Duffy are here to listen and to help.

Our staff respect your unique needs and circumstances.

Once you become a Duffy Health Center patient, you will have access to primary and preventive care and support services.

We envision Cape Cod as a community where all people have access to quality health care, safe and affordable housing, and lives filled with hope and purpose.

Medical Care • Primary and preventive care • Chronic disease management • Treatment for Hepatitis C, HIV and other infectious diseases • Onsite specialists • Nutritional education and counseling Behavioral Health • Psychiatric services • Medication management • Individual and group counseling Substance Use Treatment • Relapse and recovery support • Medications for substance use disorders • Special programs for teens and mothers Case Management • Health insurance benefits assistance • Assistance with medical care management • Connection to community services • Homeless prevention and shelter diversion • Community outreach Spiritual Care • Compassionate listening • Prayer, meditation and spiritual direction • Grief support

Who Duffy Serves We welcome persons who may be: • Uninsured • Eligible for MassHealth and other statesponsored health insurance programs • Eligible for Medicare • Unstably housed

What can I expect from team care?

Expertise Care from a team that includes primary care providers, substance use disorder clinicians, mental health and spiritual health counselors, and case managers.

Partnership Care that includes you as a respected and active member of the team, so you can help manage your own health.

Duffy accepts all patients regardless of ability to pay. We will enroll you into health insurance and other benefits programs for which you may be eligible.

A sliding fee scale is available.

Hours of Operation Monday - Wednesday: 8:00 am - 7:00 pm Thursday: 8:00 am - 12:00 pm; 2:00 pm - 7:00 pm Friday: 8:00 am - 5:00 pm Same day appointments may be available.

Call (508) 771-9599 for an appointment.

Duffy respects diversity. We offer multilingual services and welcome gay, lesbian, bisexual and transgender individuals.

Convenience Care that is easy to schedule, with early and late appointments, and new ways to keep in touch with your team.

Collaboration Care that is coordinated with other health care providers when you need it.

YOU are a part of your health care team!

NCQA Recognized Duffy Health Center is recognized by the National Committee for Quality Assurance (NCQA) for its ability to deliver quality team care and to improve health as a Patient-Centered Medical Home (PCMH).

94 Main Street, Hyannis, MA (508) 771-9599 DuffyHealthCenter.org

STRATEGIC PLAN Fiscal Years 2022 - 2024 The mission of Duffy Health Center is to provide equitable, integrated primary health care and support services to persons who are experiencing or are at risk of homelessness on Cape Cod, and to improve the quality of life for vulnerable and marginalized populations through community collaborations, leadership, and advocacy.

Strategic Priorities: Fiscal Years 2022 through 2024 Getting the “Duffy House” in Order Expanding Our Programs & Our Reach • Resource alignment to sustain operations • New programs to respond to patient needs • New tools for effective patient engagement • New populations to expand our impact Responding to Community Needs • Addressing gaps in community services

Developing Our Workforce • Diversity, safety, continuous improvement

Priorities for Fiscal Year 2022 Behavioral Health Access and Expansion: Reviewing staffing, scheduling, model of care and mode of service delivery for therapy and psychiatry.

Medical Department Productivity: Workflows, staffing, use of electronic medical records and space planning to increase daily visits by medical providers while improving quality of worklife.

Clinical and Operational Focus on Quality Improvement: Identify internal staffing resources and develop a workplan for operations improvements.

Recovery Support: Continue to expand Recovery Coaching and Recovery Support Navigation as opportunities present.

Professional Case Management: Expand professional case management services by identifying financial resources and populations needing continued wrap-around care, such as residents of public housing and those with housing vouchers of all types.

94 Main Street, Hyannis MA 02601 • DuffyHealthCenter.org

Duffy Health Center’s “Hedgehog Concept” The Hedgehog Concept comes from Good to Great by Jim Collins. It is a simple, crystalline concept that flows from a deep understanding of the intersection of three simple questions, as illustrated below. What do we do best? What drives our economic engine? What are we deeply passionate about?

The Duffy Health Center team excels at creating trusting relationships with the most marginalized persons in our community, facilitating the provision of health care for the whole person.

Vision We envision Cape Cod as a community where all persons have access to quality health care, safe and stable housing, and lives filled with hope and purpose.

Values 1. Homelessness is unacceptable.

2. Every person has the right to food, clothing, housing and health care.

3. All individuals are capable of change and personal growth, and deserve to be treated with dignity and respect.

4. Individuals experiencing homelessness or who are at risk of homelessness have complex health and social needs, and the social determinants of health must be addressed in treatment planning.

5. Effective treatment requires meeting people at their point of need as they define it and supporting their participation in decisions affecting their lives.

6. Stability and safety are the foundation on which other life goals and accomplishments are based.

7. Public policy should focus on the integration of best practices and effective solutions.

8. Financial stability is essential to a strong organization prepared to meet its mission.

Philosophy of Care We believe that every human being is worthy of respect and should therefore be treated with dignity, and that every person has the potential to change their circumstances. By providing compwwassionate, nonjudgmental care, using evidence-based practices and a patient/client-centered approach, we serve and support people to truly engage in a recovery process toward health, home, purpose and community.

Duffy Doings RESTORING HEALTH, REBUILDING LIVES

Reaching In Collaborating with the Barnstable County Sheriff’s Office to ease transitions & reduce recidivism

FALL 2021

New Year, New Hope A note from Heidi Nelson, CEO

A

s the seasons change and we enter into a new year, the fall breeze brings new hope for our future.

At Duffy we continue to fight the COVID pandemic with vigor. Cases remain stubbornly high in Massachusetts, despite our Top Five ranking in the US for vaccination rates. We continue to offer our patients vaccine appointments - a Duffy team is on the phones daily and our providers do their best to discuss, inform and encourage those in our care to be vaccinated.

Our work is further complicated as we track vaccine approvals and try to sort out when and how we provide booster shots. At this writing, we are seeking clarification on a vaccine mandate for our staff, however we are proud to report that 95% of our team is fully vaccinated!

Day after day we continue to mask up in the health center, wash hands incessantly and speak to our patients and each other through plastic barriers that sadly separate us.

At the same time we are highly optimistic about our future as we embark on our strategic plan for fiscal years 2022 through 2024. Our management team and board has prioritized five goal areas for the coming year; these initiatives are purposefully internal and operational as we improve our workflows to provide better access for our primary care and behavioral health patients.

Simultaneously we actively seek opportunities to expand our leading edge case management and substance use disorder recovery services.

And 2022 marks our 25th anniversary! We have three staff members who have recently celebrated their 20th work anniversaries at Duffy Health Center. They marvel at how the organization has changed and grown since they

began working for Duffy in the NOAH Shelter.

Over all these years, there is one thing that hasn’t changed: our most marginalized and vulnerable neighbors have complex needs.

As our mission statement proclaims, this is who we are here to serve and whose lives we seek to improve through our leadership and collaboration in the community.

Our Duffy staff have lived this mission for 25 years, and perhaps more than ever over the past 18 months. We would not be here if it weren’t for the support of our community, and we will continue to need your help to make sure that our work continues. Your gifts provide support for innovation and meeting clients’ basic needs. We cannot do it without you.

Please join me in doing everything you can to ensure Duffy continues to lead with compassion and strength, for the next 25 years!

Be well, Heidi R. Nelson, FACHE CEO, Duffy Health Center

Duffy Health Center Board of Directors Kathleen Bresette, President Susan Harrington, Vice President John Murphy, Treasurer Paulette Shaw Querner, Clerk

2

Duffy Doings

James J. Cullen Miguel R. DaSilva Michael E. Foley, Esq. 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.

Make a gift to support the Duffy mission!

Reopening Our Doors Safely bringing patients back inside Duffy Health Center

L

ike so many organizations, businesses and service providers around the country, when the COVID-19 pandemic began Duffy Health Center was forced to close its doors to patients for most in-person and walk-in visits. Given the value we place on our open, welcoming and accepting environment, it was difficult for the Duffy team to see our front doors locked. A quick shift to telehealth allowed our providers to maintain contact with patients and continue providing care, albeit over the phone. Telehealth actually helped us to re-engage some individuals who had fallen out of touch but were more comfortable having an appointment over the phone. It felt like we were making constant adjustments to how we did our work, but we carried on providing care.

Shortly into the pandemic, a staff Reopening Committee was formed. The group met frequently - and still meets - to create a carefully calculated, incremental plan for reopening Duffy Health Center to our patients. The group develops all COVID-related policies, ensuring that they are aligned with the guidelines set forth by the Department of Public Health and the Centers for Disease Control and Prevention.

The first phase of Duffy Health Center’s reopening began in the summer of 2020. We began seeing a very limited number of patients inside Duffy based on clinical recommendations from their providers. These visits were limited to patients whose medical concerns needed to be addressed in person as quickly as possible; all other visits continued to be conducted via telehealth.

Since that time, we have continued to make strides toward “normal” inside Duffy Health Center. By most measures, as of this writing we are open as we were prepandemic, but with COVID precautions still in place. We have an automated temperature machine, and front desk

staff go through a COVID screening questionnaire with patients as they arrive. All patients are required to wear a surgical mask that is offered to them upon arrival at Duffy; staff are masked at all times. There are still limited chairs inside the waiting room, and patients are now allowed to wait outdoors if they are more comfortable.

In the medical department, it has not been a challenge to bring patients back into the building. As we increased the number of in-person medical visits that were scheduled, we found that patients wanted to come in. Word travels fast in our small community, and as our administrative staff began working through lists of patients who were due for an in-person visit, they found that patients began contacting them asking to come in. Each medical provider maintains one telehealth day per week, but we are otherwise scheduling medical appointments as we were before COVID. In the behavioral health department, there has been more hesitancy to return to the building for a number of reasons, the least of which being that our patients experience a myriad of social anxieties such as agoraphobia. In these situations, we have seen that patients not only prefer therapy via telehealth but are more willing to engage with our therapists over the phone. Besides the anxieties of coming to the building, there are also the barriers that patients face - such as transportation - that are elminated when they can meet via telehealth. The challenge for the therapists, of course, is that a physical assessment is part of their overall assessment of a patient’s wellbeing, so they have been working on scheduling intermittent in-person visits for these patients.

In addition to medical and behavioral health appointments, our professional case management staff are now able to provide support to patients in-person at Duffy in conjunction with their ongoing support over the phone and through outreach in the community. The Case Management team helps patients connect to critical resources including housing, food assistance, and more.

Of course, we continue to offer COVID vaccines to all patients and other members of our community.

Providers speak frequently with their patients about the vaccine, trying to address hesitancy and misinformation.

Wednesday is our vaccine clinic day, and anyone from our community can receieve a vaccine, whether or not they are a Duffy patient. We will continue to offer this in addition to our other services for as long as needed.

Duffy Doings 3

25 Years of Service Preparing to celebrate our 25th anniversary

A

pril 2022 will mark 25 years since Duffy Health Center was incorporated as a 501(c)3 nonprofit organization in the state of Massachusetts.

As we approach this milestone, it’s truly remarkable to reflect upon the ways we have grown since our humble beginning at the NOAH Shelter, now known as St. Joseph House operated by Catholic Social Services. The timeline below shows some of the biggest landmark moments in our organizational development.

Duffy Health Center truly began as a grassroots organization, a movement begun by a handful of individuals who recognized a need in our community and decided to do something about it. Of course, this is how many nonprofit organizations were founded in the 1980s and 90s. What sets Duffy apart is its responsiveness to community needs as they’ve shifted over the years; the innovative spirit that has perpetuated since the earliest days; the consistent professionalism of staff; and a steadfast organizational culture that values dignity and respect of all human beings, no matter their current circumstances.

The clinic becomes incorporated as the O’Neill Health Center, licensed for primary care services. The clinic adjoins the Housing Assistance Corporation’s NOAH Shelter, primarily serving individuals identified as chronically homeless. Judy Best-Lavigniac, a nurse practitioner involved in the volunteer operation of the O’Neill Health Center, becomes the first executive director.

1997

Early 1990s A volunteer free clinic begins at the NOAH Shelter in Hyannis, run by nurse practitioners and Dr. Arthur Bickford.

4

Duffy Doings

As we approach our 25th year, Duffy programs and services continue to grow in breadth and depth as we respond to our community’s needs. Today, Duffy’s leadership is often sought to assist in implementing programs to support our most vulnerable and marginalized neighbors.

The Duffy team has certainly grown since its earliest days.

In just the last five years, our team has grown by 46% as we’ve added program staff to support the work of our front-line clinical teams.

We’ve grown so much, in fact, that we’ve run out of space in our bulding at 94 Main Street! We are excited to share that in the upcoming year, we will be taking over some of the office space in the neighboring buliding at 110 Main Street, moving administrative staff. All patient and client care will remain at 94 Main Street. This additional space will allow us to work as effectively as possible as we continue to provide quality health care to the neighbors who need us most.

Stay tuned for updates and plenty of opportunities to celebrate our 25th year with us!

Under the leadership of our second executive director, Claire Goyer, in the 2000s the health center becomes a licensed mental health clinic and develops state of the art, evidence-based case management programs, including the Housing First initiative through MassHealth.

In 2006, the health center’s legal name officially changes to Duffy Health Center.

Duffy Health Center moves into our current home at 94 Main Street, bringing all of our programs under one roof. Our client census expands from 2,600 to over 3,300 with increased physical space for care and an expanded eligibility definition of homelessness to include persons who are living doubled up with others or otherwise unstably housed, as well as those living in poverty.

2006

2002 The O’Neill Health Center receives a federal Health Care for the Homeless grant from the Health Resources and Services Administration (HRSA). This enables expansion to a second site. As a HRSA grantee, we operate under federal guidelines specific to clinical practice, operations and Board of Directors oversight.

2011

2010 The Affordable Care Act is passed.

This fuels Duffy’s growth as HRSA invests ACA funds into community health center integration, bringing mental health and addiction treatment services into the primary care setting. The move effectively creates “one-stop-shopping” for low income and vulnerable populations, thus improving access to care.

2020 Duffy staff and managers are regularly called upon for advice and guidance and to teach others.

Duffy Health Center is publicly recognized for our irreplaceable role in the community’s response to the COVID-19 pandemic.

94 Main Street, Hyannis MA DuffyHealthCenter.org

“A Calm Busy-ness” Dr. Lisa Jones, FACOG, CPE, joins Duffy Health Center as Chief Medical Officer On September 7th, Dr. Lisa Jones, FACOG, CPE joined Duffy Health Center as Chief Medical Officer. Before she had officially started, we had the opportunity to talk with her and learn more about her background, her experiences, and the path that led her to Duffy Health Center.

--------------------------------Tell us a little bit about yourself.

Before coming to Duffy Health Center, I was at Greater New Bedford Community Health Center for almost 15 years. I first started as a part-time gynecologist; they had never had a gynecologist on staff before, much like Duffy.

I eventually moved on to managing the women’s health department. This was a practice within Greater New Bedford Community Health Center that was specifically created for women with trauma or other negative experiences; those who were more comfortable in a women-for-women practice.

I ran the women’s health department for 10 years, and somehwere along the way I volunteered (or was voluntold!) to join the quality committee. From the outset, I really liked it. I was interested in the standardization of care and improving the quality of care. Eventually, I became Chief of Quality and Compliance.

I was responsible for quality, patient satisfaction, incident reports, our relationship with the accountable care organization, and more. I eventually realized that in this role, I was the voice of the patients on our executive team.

And it turns out, that’s the part of medicine that interests me most: the stories that people have, the opportunity to talk to patients to learn what they need, to help them become their best selves. It’s why I went into medicine tin the first place. The role felt not only incredibly important but also very natural to me.

At Duffy, I’m interested in pulling the patient perspective into the Chief Medical Officer role. I’d like to make sure that we’re never losing sight of the reason that we’re all here in the first place, which is patient care. I taught high school briefly before going to medical school, and I see a lot of similarities between teaching and medicine: it’s our job to help people see whether or not we have anything of value to offer them and help them incorporate that into their lives.

interviews and the feeling in the space when I came onsite.

I was impressed with what appeared to be a very egalitarian interview process.

Everyone seemed genuinely interested in making sure myself or any other candidate was a good fit. In order to find a good fit, you need to have a solid sense of the culture. The sense that I got from the interviews was that everybody was very grounded in the Duffy mission and that’s what they were looking for and thinking about in the interview. That’s incredibly important to me. It was really impressive.

When I came onsite, the whole site seemed to be very active, but calm at the same time. It’s a calm busy-ness.

Nobody seemed harried, nobody seemed angry or grumpy to be at work. Everyone generally seemed to be happy to be here and happy to be working with the patients we’re working with. It speaks to leadership for creating an environment where that kind of culture can thrive. It’s the difference between controlled, harnessed energy and chaos.

What are your goals at Duffy Health Center?

In the short term, my goal is to absorb and learn as much as possible. Every community health center is facing a lot of the same challenges: the ongoing, long range impact of COVID; the volume of visits per day; team productivity; maximizing in-person time; making sure things are as efficient as possible.

What made you choose to join Duffy Health Center?

I see it as a stool with four legs: quality care, efficiency, patient satisfaction and team satisfaction. Each leg is equally important, and many people working at community health centers are struggling right now with a particularly challenging set of patients during a particularly difficult time. We will need to figure out how best to maximize productivity while looking out for providers’ wellness.

Every job looks the same on paper, but what made the difference for me when I was interviewing at Duffy Health Center was the culture that I picked up during the

Please join us in welcoming Dr. Lisa Jones to the Duffy Team!

Duffy Doings 5

Reaching In

Duffy Health Center’s working relationship with the Barnstable County Sheriff’s Office A statement from the Barnstable County Sheriff’s Office: “Duffy Health Center has been coming to the Barnstable County Correctional Facility since 2012. Through collaboration with Barnstable Count Sheriff’s Office’s (BCSO) reentry, medical, and mental health services, Duffy has helped ensure continuity of care to meet the medical, mental health and addiction recovery needs of those individuals being released to the community. Duffy’s services at BCSO significantly increase the likelihood that incarcerated individuals will follow-up with the care needed to maintain their physical and emotional health and sobriety upon their release. The BCSO is very grateful for its partnership with Duffy Health Center and its focus on reducing the risk of recidivism and relapse, as well as improving the quality of life, for its shared clients.”

E

very other Friday, Lisa Perkins, LICSW (pictured on front cover), starts her day at the Barnstable County Correctional Facility (BCCF). She arrives with a list of up to 6 names of incarcerated individuals who she will meet in her 2 hours at the facility. Lisa receives the list of names prior to her arrival, and she spends time preparing for her meetings by finding any background information that may be in the Duffy medical records regarding their health history. Lisa is granted access to the facility as if she is an employee, which she recognizes comes with a huge amount of trust and faith in this collaboration.

At its outset, the relationship between Duffy Health Center and the Barnstable County Sheriff’s Office (BCSO) consisted primarily of the provision of medication for opioid use disorders to individuals who were nearing their release date. Vivitrol (naltrexone), the medication prescribed, assists in reducing the urge to use opioids and alcohol by blocking the pleasurable feelings produced by using. By pairing one shot of Vivitrol pre-release with a follow-up appointment at Duffy Health Center for a second dose, the collaboration was designed to prevent the all-too-common occurrence of fatal overdose upon release from incarceration.

When Lisa took over the program in 2015, it soon became clear that the inmates’ needs went much further than just medication for opioid use disorders. In true Duffy fashion, Lisa began to shift the “in-reach” she does at BCCF to more of a whole-person approach. She works closely with the BCSO reentry, medical, and mental health teams inside the 6

Duffy Doings

the Correctional Facility to ensure a true continuity of care.

Inmates receive support from the reentry program during the 60 days leading up to their release, including a case manager and, when needed, a recovery support navigator who remains engaged up to 6 months after release. The role of Duffy Health Center, and Lisa as the liaison, is to bridge these services so that the individual has the same types of support in the community so that they can follow through on the reentry plans made prior to their release.

Lisa reflects, “Over the last 20 years or so, people started to notice that we have some very mentally ill people in our community who keep ending up back in jail. There used to be facilities where they could be safe and stay stable, but with those gone the justice system has turned into the mental health system. Luckily the Barnstable County Sheriff’s Office understands that mental health is a huge part of recidivism. We can’t just let people out into the exact same situation they were in before incarceration their lowest low - and expect them to do okay. They need support.”

Lisa sits in an interview room with the individuals she meets, conducting a short intake process similar to what is done when a person establishes as a patient at Duffy Health Center. They discuss housing, needs related to their

medical and behavioral health, and psychological and recovery support needs. From this conversation, Lisa then determines what appointments this individual may need with members of the Duffy team: who on the Duffy team should be involved with their care? With their consent, she sets up all needed appointments: with the Connections team to establish as a patient; primary care; Medication Assisted Treatment for Substance Use; therapy with our Behavioral Health team, and more. Inmates have health insurance thanks to the efforts of the reentry team at BCCF prior to their release.

As the relationship has deepened between the two agencies, so too, has the communication. It is a true partnership, where a signed release by inmates allows the BCSO medical staff to share medical records upon release with Duffy Health Center as the primary care provider.

It goes in the opposite direction sometimes, as well: a Duffy patient may become involved with the justice

system, interrupting their care. For patients in our Hepatitis C treatment program, for example, Lisa is able to work with the head nurse at the BCSO in order to get special permission for a patient inmate to continue their medication and follow up testing.

Duffy team members know that Lisa will be at BCCF every other Friday, so they will ask her to check in on a patient they know is there. “They’re so glad to know that someone is thinking about them, that someone cares how they’re doing,” she shares. “I work hard to build a rapport with these individuals, and they seem to appreciate me coming in. To them, I’m a friendly person who is working to get them what they need ‘on the outside.’ I’m a native Cape Codder, and I’m happy to be able to help people in my community who are struggling.”

We wish Sheriff James Cummings all the best in his upcoming retirement.

Diversity, Equity & Inclusion Our commitment to the work

I to:

t’s been one year since we shared our action plan to support Diversity, Equity and Inclusion (DEI) at Duffy Health Center. At that time, we made the commitment • carefully examine our policies and procedures to identify and reconcile structural racism, • increase the representation of Black, Indigenous, People of Color on our staff and our board to more fully represent the populations we serve, • implement meaningful trainings for new hires and ongoing trainings for staff and board on issues of DEI, and • undertake reviews of care to ensure access to and equitable delivery of all health care services we provide.

pro-bono, with the blessing of leadership at BHCHP. Sonja has an extensive background in diversity, equity and inclusion work, leading BHCHP through initiatives to center equity and racial justice in all aspects of their work. She recently met with Duffy Health Center’s Board of Directors, sharing BHCHP’s DEI initiatives. She is now partnered with Duffy’s DEI Committee as well. We are very grateful to Sonja, her colleague Morgan Ward, and the Boston Health Care for the Homeless Program for their support of Duffy Health Center’s DEI efforts.

We’d also like to acknowledge a grant received from the Rockland Trust Charitable Foundation to support this work. Thank you!

Since last year, we have established a staff-led DEI Committee that meets monthly. Recognizing the complexity of this work, the group has taken time to iterate on the workplan several times. There is a focus on sharing and exploring educational resources to better understand the impact of systemic racism on the individuals in our care and within our community.

From the outset, members of the committee unanimously agreed that it would be best to hire a consultant to guide this work. We are happy to share that Sonja Spears, Chief Equity and Inclusion Officer at the Boston Health Care for the Homeless Program (BHCHP), has offered her expertise to support Duffy’s DEI work. Her services are being offered Duffy Doings 7

Quality-Focused Internship Meet Medical Doctor Candidate Joey Tella

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oseph “Joey” B. Tella spent the summer of 2021 as an intern at Duffy Health Center after completing his first year of medical school at Dartmouth College. Joey grew up in Medfield, Massachusetts, but is connected to Cape Cod through his grandmother, a resident of Eastham.

While most medical school students seek out research positions after their first year, Joey already held two research positions, one during his undergraduate studies at Northeastern University and another at Boston Children’s Hospital. In his search to do something more community-oriented after his first year, he was connected to Duffy Health Center. “I felt like it would be a wonderful opportunity to give back to a community that had afforded me so many wonderful memories,” he shares.

Joey’s placement at Duffy Health Center ended up being rather serendipitous: he came on to provide support to the team working on improving rates of colorectal cancer screening, and had just completed his gastrointestinal block at school. Colorectal cancer screening is a key quality initiative at Duffy, so it also helped that he had just completed a course on quality improvement.

Screening for colorectal cancer is a national priority because it is a life-saving measure: in 90% of cases, a life can be saved through early detection. In general, Duffy patients are navigating complex health issues, placing their focus on day-to-day ailments rather than preventive care. Through education and referrals from Duffy providers, early detection can have a major impact on the lives of the 37% of Duffy patients who are over the age of 50 and thus at higher risk for colorectal cancer.

The goals of the Duffy team working on colorectal cancer include patients’ completion of the at-home fecal immunochemical test completion rate, the colonoscopy completion rate, the follow-up colonoscopy rate; and the overal colorectal cancer screening rate.

Joey provided invaluable input as he applied the clinical microsystem approach to quality improvement learned at Dartmouth to address issues of access for patients and investigate where and why they were facing road blocks.

“Instead of looking at the big picture first, you start by breaking it down to the smallest unit within the system.

In this case, it was the patient-provider interaction,” says Joey. “What was happening in that interaction and how could we make it better?” Joey walked through the process as if he were a patient himself, then 8

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developed a map to gain a visual sense of the process. ”Once you have it laid out visually, it’s much easier to identify the small tweaks that can be made that make a big difference for both patients and providers.”

As part of his research, Joey visited the gastroenterologists to whom Duffy refers to learn more about their requirements, communications with patients, and expectations. One example of a “small tweak” that will make a big difference for those in our care was communications. “As it turns out, the offices will call you up to three times to schedule your appointment, then they’ll take you off the list,” shares Joey.

Given the challenges our patients face, many of them change phones often or are without a phone for a spell of time. Rather than have them disengaged from the process because of this, Joey was able to help facilitate a change whereby the specialists’ office add a Duffy case manager as an alternate contact in case they have trouble reaching the patient. This way, patients don’t get removed from the gastroenterologists’ lists before Duffy has the opportunity to provide support in contacting the patients. This small change will have a big impact for many patients.

Before the end of his time at Duffy, Joey presented his findings to the team working on colorectal cancer screenings and made recommendations on additional tweaks to improve the process. He also developed educational tools for providers to share with patients.

“I really loved working at Duffy this summer. I felt like I was welcomed as part of the team, and it was so good to see all of the teams working so closely together. The idea of ‘wrapping around’ the patients is something that will stick with me,” says Joey.

We are grateful to Joey for spending his summer with us and making such important contributions to our work!

Equal Value Placed on Mental Health Services

Massachusetts equalizes payment for mental health services and primary care

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n June, community health centers across Massachusetts received good news from the state: as of January 1, 2022, MassHealth, the state’s Medicaid program, will reimburse for mental health services at the same rate as primary care services.

We are grateful to the Baker Administration for the magnitude of this historic, systemic investment, which will be a game changer for health centers like Duffy and the community we serve. The implementation of these rate increases will transform our underlying finances and allow us to significantly increase the amount of care we can deliver to our communities. That means more medical and behavioral health services to keep pace with patient demand. We are also thankful to our legislative leaders and champions for their efforts to highlight the value, effectiveness, and untenable financial distress of health centers over so many years.

This investment is the culmination of years of work and advocacy by the Massachusetts League of Community Health Centers to secure financial relief through a payment methodology that supports the health center model of care. Stabilizing and empowering health centers as primary care leaders is pivotal as we look to a more equitable post-COVID future. Making these changes now will also ensure health centers are well positioned for the health care delivery system of the future.

Massachusetts health centers have consistently stepped up to take on the challenges of expanding access to care, serving many patients in languages other than English, providing dental and behavioral health services at a financial loss, and tackling some of the really tough issues related to substance use disorder treatment.

However, unlike what is the case for health centers across the country, the reimbursement model in Massachusetts has not supported this comprehensive model of care. For example, while health centers nationally have become financially stronger under health coverage expansions like the Affordable Care Act, Massachusetts health centers have not, as reimbursement has fallen short of supporting the comprehensive care provided to increasing numbers of individuals who have sought services at health centers post-health reform.

As Duffy’s Chief Financial Officer Jeffrey S. Dykens observes, “The equalization of rates is long overdue.

We’ve been suffering on the behavioral health side of things; medical visits have essentially been subsidizing them. With this change, the state is acknowledging the importance of mental health services and recognizing the value of the services that federally qualified health centers like Duffy Health Center provide.”

For Duffy Health Center, the increased economic stability that will come with this rate change will allow us to: • • • •

Pay competitive salaries to better recruit and retain clinical and administrative staff, Increase our patients’ access to behavioral health services, Ensure better wages for our entry level workers, many of whom are hired from the community, and Be on stronger footing to participate in imminent state value-based payment models.

Duffy is a proud member of the Massachusetts League of Community Health Centers and Duffy’s Chief Executive Officer Heidi Nelson sits on its Government Affairs Committee.

We are grateful for the group’s leadership in advocating for important issues that have a significant impact on health centers across the state. To learn more, visit MassLeague.org.

(Source: Massachusetts League of Community Health Centers’ Talking Points for Health Centers Regarding MassHealth Announcement of New FQHC Payment Methodology and Investments in Health Centers)

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Innovative Treatment for Substance Use Disorders Responding to the opioid epidemic with innovative programs

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uring the COVID-19 pandemic, communities around the world saw an increase in substance use, and ours was no different. Feelings of uncertainty, isolation, and hopelessness were universal, and especially impacted individuals with substance use disorders; those active in their use as well as those in recovery.

Duffy’s Medication Assisted Treatment (MAT) team offers evidence-based outpatient treatment for substance use disorders coupled with primary care, medication management, counseling, and more. Throughout the pandemic, the MAT team has remained steadfast in their commitment to providing same-day access to individuals seeking treatment. As MAT Clinical Coordinator Jennifer Carroll, CARN states, “If someone is ready for treatment today, the use isn’t going to stop if they have an appointment next week, and each day that goes by, a person’s life is at risk.”

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As represented in the graphic above, Duffy Health Center has several substance use disorder programs that support and complement the work of the MAT team. In response to the increased need in our community, these programs have grown in size and scope over the course of the past two years.

Recent developments include: •

The Moms Do Care team provided increased support to moms enrolled in the program throughout the COVID-19 pandemic. Program staff, which includes a Certified Addictions Registered Nurse and Peer Recovery Coaches with lived experience, assisted women in accessing additional resources and provided connection and increased emotional support during this time of isolation. With the recent renewal of the program’s state-funded grant, the team will broaden the scope of the program beyond moms

with a history of opioid use disorder to include moms with any history of substance use disorder.

•

Duffy Recovery Support Navigators, who provide non-clinical services to individuals seeking recovery, provided support to over 500 unique individuals through over 3,200 in-person encounters from July 1, 2020 to June 30, 2021. They played a large role in staffing Duffy’s outdoor shower program during the first year of COVID, providing critical support and connection to many of our patients who may be living outdoors. The Recovery Support Navigators also facilitated care by delivering medication to quarantined patients, distributing donated USDA food boxes to patients in need, and more.

•

In 2021, Duffy began to integrate Certified Recovery Coaches into the scope of supports offered for those seeking recovery. These team members work individually with patients for 6 months on their recovery journey. Together with the patient, they create a wellness plan and a relapse prevention plan, building up for independent success in their recovery.

Duffy has been awarded a grant of $568,000 over 3 years from the federal Substance Abuse and Mental Health Services Administration and the state Bureau of Substance Addiction Services to support the implementation of the Recovery Coach program.

•

Along with the Community Health Center of Cape Cod and AIDS Support Group of Cape Cod, Duffy Health Center is part of the Community Harm Reduction and Treatment team, a mobile clinic launched in 2021 providing substance use disorder services. The team, which includes a Harm Reduction Specialist and Recovery Support Navigators, is based out of a mobile clinic that travels throughout the targeted service areas of Bourne and Sandwich multiple days per week. They provide harm reduction services including connection to telehealth appointments for medications for opioid use disorder, same-day access to prescriptions, access to overdose prevention education, and naloxone distribution.

•

Duffy was recently awarded a grant for $315,000 to support the RecoveryBuild Alternative Peer Group (APG), a collaboration with Behavioral Health Innovators, Inc. The APG is a 6-month outpatient treatment program for Cape Cod teens struggling with substance use challenges. Teens in the APG have the opportunity to obtain support for their substance use challenges with the expert guidance of a Licensed Mental Health Counselor, a Family Therapist, a Recovery Coach and a Peer Mentor with lived experience. The program is built to help teens achieve their goals and celebrate successes along the pathway of recovery. It is a safe space where fun is an important element in helping teens build lasting, healthy friendships.

Patrick Graham Charitable Foundation Providing support to moms in recovery After their son Patrick passed away from a drug overdose in 2017, Patricia Graham and her family established the Patrick Graham Charitable Foundation in his memory. The guiding principle of the foundation is that no one should suffer alone from a drug addiction or feel shame associated with the disease.

In September, Patricia Graham and other supporters of the Patrick Graham Foundation came together to support mothers and children in Duffy’s Moms Do Care program.

Their donations of diapers, wipes, bottles and other baby supplies will go directly to pregnant and parenting women with a history of opioid use who are working to maintain their recovery. We are so grateful for the support of the Patrick Graham Charitable Foundation and its supporters!

Patricia Graham (left) loads up the donations.

The Moms Do Care team (right to left): Alicia Gapstur, CARN; Sarah Ducie, Recovery Coach Supervisor; Cheri Cooper, Peer Mom; Abby Weber, Recovery Coach.

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Duffy in the News Moms with opioid use disorder cope with pandemic’s monumental changes as seen in The Cape Cod Times In April, Peer Recovery Coach* Sarah Ducie from Duffy’s Moms Do Care program was interviewed for a feature in The Cape Cod Times about how the COVID-19 pandemic was impacting moms in recovery from opioid use disorder. Times writer Jeanette Hinkle followed Sarah through a day of work to document all the ways she provides support to women in the program, from preparing for a custody hearing to assisting with daily schedules and finding a bed at a detoxification facility. The full article can be found on The Cape Cod Times website. * Since April, Sarah Ducie was promoted to the role of Recovery Coach Supervisor.

Race and Inequity in Substance Use Disorder Treatment and Recovery as heard on The Point Institutionalized racism in the US contributes to disparities in health and substance use disorder among people of color compared to white people. Research shows people of color experience more barriers to treatment than whites, have difficulty finding treatment programs that meet their needs, and experience racism and microaggressions when in treatment. We discuss the roots of these disparities and efforts to bring more equity in healthcare and treatment. (From capeandislands.org) Danny Rodrigues, Associate Director of Substance Use Disorder Services, and Duffy Board member Dr. Corrie Vilsaint, Principle Investigator at the Recovery Research Institute and Center for Addiction Medicine at Massachusetts General Hospital, and research fellow at Harvard Medical School were featured in this facinating interview. Listen at CapeandIslands.org.

Duffy Health Center expands teen substance use services as seen in The Cape Cod Times Since 2018, Duffy Health Center has partnered with Behavioral Health Innovators, Inc. to provide clinical supervision and administrative support to the RecoveryBuild Alternative Peer Group (APG), an evidence-based program for teens struggling with substance use challenges - the only program of its kind on Cape Cod. Duffy was recently awarded a grant for $315,000 to support the continuation and expansion of the program.

RecoveryBuild APG is staffed by a multi-disciplinary integrated team, including a program supervisor, licensed mental health therapist, peer mentor with lived experience, certified recovery coach, and a family therapist to support families.

The program is open to teens between 13 and 17 years old with a history of substance use. The team also supports and provides resources to their family members.

RecoveryBuild APG meets twice weekly, and thanks to this $315,000 grant from the State’s Executive Office of Health and Human Services (EOHHS) and the Department of Public Health (DPH), we are expanding services to Pleasant Bay Community Boating facility in Harwich and The Falmouth Recreation Center. Learn more at RecoveryBuild.org.

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Expert Commitment Certified Addictions Registered Nurses at Duffy Health Center Written by Friend of Duffy, Colleen LaBelle, MSN, RN-BC, CARN, Founder and Director of Boston Medical Center’s Office-Based Addiction Treatment (OBAT) Center and director of their OBAT Training and Technical Assistance program.

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uffy Health Center began treating substance use disorder (SUD) in the early 2000s, when the FDA first approved the use of medications to treat addiction in primary care. Duffy’s leadership and medical team have worked tirelessly to expand their scope and to be a leader on the Cape in caring for patients with SUD. They’ve built robust behavioral health services, expanded the role and the numbers of recovery coaches; they treat pregnant women and their families while advocating for and educating others.

Duffy Health Center’s CARNS (right to left): Alicia Gapstur, Jennifer Carroll, Sydney Cochran, and John Barboza, formerly of Duffy Health Center.

Culture of Safety One of our top priorities at Duffy Health Center is maintaining a culture of safety and security for our patients and staff. Given that we serve many individuals with severe mental health challenges, it is imperative that we have systems in place to prevent incidents. All of our staff are trained in crisis prevention and intervention so that we may de-escalate individuals who may become upset.

When COVID-19 forced us to close the doors of our

Nursing certification demonstrates expertise and commitment to a specialty nursing practice. The Certified Addictions Registered Nurse (CARN) credential is highly regarded as a standard of excellence, promoting evidence-based practice in caring for and supporting patients, families, and communities, and expanding the research while integrating the research with practice.

Obtaining one’s CARN is not an easy task, as accreditation is a journey and a lot of hard work. The pass rate for the exam in 2020 was 74%.

Duffy has walked through the journey to CARN certification with four nurses, the latest being Jennifer Carroll who was “pinned” earlier this month. The Duffy Team cares for the complexities of patients with substance use disorder in their community, providing evidencebased, state-of-the-art care. These nurses are working at the top of their license alongside leadership, mental health and primary care providers, recovery coaches and recovery support navigators to set the bar for exceptional care. Together they are able to do this seamlessly.

Community health centers such as Duffy are critical in addressing the substance use issues in our communities.

Providers need to emulate the successes at Duffy to expand access to treatment, to provide evidence based treatment, and to remove barriers and stigma in order to truly expand care and change outcomes not just in Massachusetts but nationally. Our community health centers are well positioned to take this on and make a difference.

Thank you to Colleen for her kind words, and congratulations to Jennifer Carroll and the rest of our Certified Addictions Registered Nurses for their work.

building, it did not stop patients from coming to Duffy to seek out services, especially at the outdoor shower program in the parking lot. Additional federal funding allowed Duffy to contract with a security company so that we could maintain a presence outdoors. As such, we hired a full-time security presence.

While we were sensitive about not creating an institutional feeling, our patients have built friendly relationships with our security guard, Pete Santos. They express that they appreciate his presence because they know that they are safe here, which is our goal.

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Community Success Joining with our community to support the mission of Duffy and other local nonprofits

July 2021: 5th Annual Charter Fishing Cup Duffy Health Center was honored to participate for the first time in the Charter Cup Fishing Tournament, organized by E.J. Jaxtimer.

Our team was sponsored

by Wendy’s and Nauset Disposal. We raised over $17,000 through this great event!

Clockwise from top left: Duffy CFO Jeff Dykens, Director of Development & Community Relations Sara Grambach, CEO Heidi Nelson, Board President Kathleen Bresette; Nauset Disposal’s Shawn DeLude unloads fish caught by the team.

August 2021: 49th Annual Falmouth Road Race For the first time, Duffy Health Center participated in the Numbers for Nonprofits program in this year’s Falmouth Road Race. The team was made up of 10 local women who came together to raise over $16,000 in support of the mission of Duffy Health Center!

Left to right: Samantha Cronin, Amanda McGerigle, Kim Neidermire, Christina Wiseman, Kate Lena, Taylor Parmenter, Melissa Hyer-Mitchell, Brenna Lapsley and Sarah Lapsley-Martin.

Not pictured: Sara Grambach 14

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Partners in Harm Reduction Duffy Health Center and AIDS Support Group of Cape Cod

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arm reduction is defined as a set of practical strategies and ideas aimed at reducing the negative consquences associated with drug use.

As we know from our work at Duffy Health Center, the disease of addiction is one that requires time and patience to heal. On an individual’s recovery journey, there are many points where missteps may be made. If we can assist in reducing the harm caused at these crucial junctures, an individual is more likely to find recovery.

The AIDS Support Group of Cape Cod (ASGCC) is a local leader in harm reduction strategies. The organization has offices spanning the Cape, in Falmouth, Hyannis and Provincetown, as well as mobile units in Falmouth, Bourne and Sandwich, and part-time staff on Martha’s Vineyard.

As their name suggests, ASGCC provides support services for individuals living with HIV, but their programmatic range is not limited to this diagnosis. They also offer screening and prevention services for sexually transmitted infections and substance use disorder services such as syringe services, education about safe injection, overdose prevention and referrals to treatment.

ASGCC’s services are cost-free and anonymous; part of their harm reduction model includes an ease of access for individuals who may be uncomfortable entering a traditional health care setting. ASGCC is also our local overdose education and naloxone distribution site, providing naloxone (Narcan) to individuals struggling with substance use disorder to prevent fatal overdose.

Duffy Health Center and ASGCC have a strong collaborative relationship based on a shared set of values and a strong belief in harm reduction. Our formal partnership began through Duffy’s Hepatitis C program.

As we know, intravenous drug use is a high risk factor for contraction of Hepatitis C. When Duffy first launched a program to treat and cure Hepatitis C, it was clear that ASGCC would be a strong partner in this work given their proximity to individuals in our community with substance use disorders. The organizations now work together on an ongoing basis to provide a low-threshold access to care: if ASGCC testing shows a positive result for Hepatitis C, their health navigators can easily refer that individual to Duffy Health Center for follow-up care. The same is true for individuals diagnosed with HIV who are in need of treatment.

“Our partnership is strong because we offer complementary services,” says Kate Lena, former Hyannis Program Manager and Harm Reduction Lead at ASGCC.

“Both organizations are responsive and innovative, proactively creating programs to address trends as they arise within our community. We have a similar approach to our work and to the people we serve; they are respected and honored as human beings, even while in active use.

This allows people to be open and honest with us and enables us to provide support.”

The most recent shared venture for ASGCC and Duffy Health Center is the Community Harm Reduction Treatment (CHART) team, a project led by the Community Health Center of Cape Cod. As part of the HEALing Communities Study, funded by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA), the CHART team is based out of a mobile clinic that travels throughout the targeted service areas of Bourne and Sandwich multiple days per week. Team members include a Harm Reduction Specialist and Recovery Support Navigators who provide harm reduction services including connection to telehealth appointments for medications for opioid use disorder, same-day access to prescriptions, access to overdose prevention education, and naloxone distribution.

We are grateful to work alongside AIDS Support Group of Cape Cod in reducing harm to vulnerable members of our community.

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Wellness on the Water A unique experience featuring local studios, teachers and wellness leaders from across our community.

Tickets: $150 in-person | $75 virtual Vaccination is required for this event. | Masking is recommended when not eating, drinking, or on your mat.

Visit DuffyHealthCenter.org/wellness to learn more and purchase tickets! @wellness_on_the_water 16

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@wotwcapecod

Good News Stories Reminding us why our work is important Duffy Case Manager, Cathy Finn, has made it her mission to collect stories of good news from around Duffy and share them in a weekly email, “Good News Wednesday.”

Here are some highlights!

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local woman had observed one of our patients, a man with a dog, for some time. When she finally spoke to him, she learned his story: he had been experiencing homelessness for quite some time, living in a tent for at least five years. Upon hearing this, the woman made a decision: she and a few friends chose to help this gentleman out of the circumstances of homelessness. Because housing is in such desperate, short supply on the Cape, they opted to buy him a van. They refurbished it and paid the insurance and registration for a year. He can live in this van until he gets a housing voucher, which is in the works through his Duffy Team.

Case Manager Arlene reports that this gentleman is now approaching life with a different perspective, thanks to his van and the time he was able to spend out of the elements in a motel this winter through the In From The Streets program, which Duffy manages on behalf of the community. She shared that he seems calmer and more centered; safer and healthier, thanks to the generosity of his neighbors.

On behalf of Duffy, we would like to let this group of neighbors know that we appreciate them taking the time to understand this gentleman and performing such a huge, life-changing deed on his behalf.

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urse Practitioner Kyle Chaplic recently received this note from a patient:

This thank you is long overdue. Knowing I have the best team of doctors working to get me well; and you being at the top of the list. I am very blessed to have found you.

I’m sure I would be at an inpatient facility due to the amount of pain I’m dealing with if not for you. My daily routine is almost normal and I know the mess I was without pain management. You’re in my prayers nightly. Wishing the best for you and yours.

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ase Manager Cathy Finn has been working with a gentleman who struggles with his mental health.

He battles with different issues, and has lived in the woods for an extended period of time. In the last few months he has had one difficulty and disappointment after another.

He and Cathy talk on a nearly-daily basis. She referred him to Recovery Support Navigator Nicole for assistance managing his recovery; she speaks to him frequently and is a major support for him. Lisa is his therapist; he greatly appreciates both ladies.

One day, he called Cathy and started out as he usually does: happy and chipper, saying how even though he had recently been dealt another blow, he was doing fine and had great plans for self care that day, including calling Nicole to tell her how great he was doing. He did say, however, that he had just missed his therapy call with Lisa, and asked Cathy to see if Lisa could talk with him for the remaining time, which she did.

After his session, Lisa called Cathy. She said this gentleman was in a very bad place; he was feeling a lot of pain and was very depressed. He had started drinking again and he needed help. Cathy shares, “I was gobsmacked. This was not the gentleman I had spoken to an hour before, so I immediately called him up.”

When Cathy reached out to him again, he admitted he was not doing well. “Why did you tell me how great things are?” she asked.

He said, “When I talk to you, I’m trying to make myself better and change my attitude. I want to be better. When I talk to Lisa and Nicole, I talk about what is wrong.”

Nicole was able to connect with this gentleman as well, reporting to Cathy and Lisa that they spoke extensively and she was trying to make a plan for dealing with his problems that he would accept (quite a challenge for him at this point).

He has an appointment upcoming with his therapist, and has the phone numbers for Nicole and Cathy. He knows where he can get help, and has, on his own, assigned to each of his team members a role in his (hopeful) recovery.

In reflecting on this dynamic, Cathy says, “Since we all support him, interact with him, and care for him, I can play my role and know he is safe with the his other supports and, as he knows, we all interact with his needs in mind.”

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Summer Solstice Celebrating those who have overcome homelessness

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ach year on the Winter Solstice, the first day of winter and the longest night of the year, Homeless Person’s Memorial Day events honor individuals who have lost their lives while enduring homelessness. On the Summer Solstice, the first day of summer and longest day of the year, several cities have begun to celebrate those who have overcome homelessness, and to affirm that we can end homelessness for everyone. This year Duffy Health Center took this opportunity to join together with friends and supporters to celebrate the Summer Solstice and Duffy accomplishments at The West End in Hyannis.

Clockwise from top left: Board member Kurt Raber with Daniela De Paula, Kareem Sanjaghi and Olympia Ramos of Cape Cod Five; Jamie Pina and Karen Herrand, organizers of the Ride for Opioid Addiction Recovery; Reverend Connie Bickford and Board Vice President Paulette Shaw Querner; Duffy CEO Heidi Nelson with Bob Duffy, Jr. and Pamela Duffy; Fred Fried plays music.

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Clockwise from top left: Dick and Michelle Fairbanks with Duffy Board President Kathleen Bresette; Board members Susan Harrington (left) and Dr. Corrie Vilsaint (right) with Patricia Cawley, Senior Director of Program Services (center); Wendy’s owner and former Board member Usama El-Sehrawey and wife Stephanie; Emily and Jeannie Botsivales.; Love Live Local CEO Amanda Converse with Duffy CEO Heidi Nelson.

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Thank You to Our Sponsors For their ongoing support of our work!

94 Main Street Hyannis, MA 02601

Non-Profit Org. U.S. Postage PAID Permit No. 58 Hyannis, MA

Duffy Impact: Fiscal Year 2021

Dear Friends, As we embark on our 25th year, we know that now more than ever, the innovation, strength, and passion our team brings to the critical work of caring for our most marginalized neighbors is vital to the health of our greater community.

COVID-19 exacerbated the daily challenges faced by our patients and clients, including access to mental health services, management of chronic conditions, and treatment for substance use disorders. Our care teams shifted to a focus on COVID-19 prevention and mitigation, and outreach to ensure the safety of those most at risk. Our administrative teams took on the challenges of navigating new funding streams and problem-solving on the fly, every day. Our quality improvement and care coordination teams focused on the effectiveness of our delivery of care to ensure the best outcomes for our patients.

This past spring, our board, leadership and staff embarked on the process of creating a Strategic Plan for 2022 through 2024, facing the challenge of “planning” in the midst of ongoing uncertainty.

Not-for-profit organizations like ours are often “building the plane in mid-flight:” focusing on internal improvements while also addressing external needs. So it’s not surprising that our goals for the coming year include: • • •

Improving internal workflows and processes, specifically the optimization of telehealth and effective use of our space at 94 Main Street.

Expanding staffing and service delivery within our Behavioral Health department to meet the increased demand for mental health services.

Positioning ourselves to expand our models to provide additional care coordination, case management, and substance use disorder support services as our team’s expertise continues to be sought by community partners.

It stands true today as it has for the last 25 years: our work would not be possible without the remarkable contributions of our staff. Their relationships with our patients and clients and commitment to their work are second-to-none. Their service to our mission is demonstrated each and every day. We are hopeful and prepared for our 25th year and beyond.

We remain grateful to you who understand the importance of our mission and continue your generous support of our work.

Thank you!

Heidi Nelson CEO, Duffy Health Center

Kathleen Bresette President, Board of Directors Duffy Health Center

2,863 patients served

by Duffy Health Center in fiscal year 2021

Our patients and clients have a higher utilization rate for our services, as illustrated below.

“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 Health Center Patient

Vanessa has been a patient at Duffy Health Center for over 7 years. During that time, she’s made tremendous personal progress, but also faced significant setbacks. With the support of her Duffy care team, she’s overcome obstacles to maintain her recovery and continue on her journey of personal growth. Vanessa is also part of Duffy’s Consumer Advisory Board. We are grateful to Vanessa for sharing her story in this candid testimonial.

Click here to hear her moving story of recovery and care at Duffy Health Center.

Quality Initiative: Colorectal Cancer Screening This year, Duffy Health Center was selected as one of three community health centers state-wide to participate in a learning collaborative focused on the prevention of colorectal cancer. The collaborative is organized in partnership with the Massachusetts League of Community Health Centers and the Massachusetts Department of Public Health, funded by the Centers for Disease Control and Prevention.

Screening for colorectal cancer is a national priority because it is a life-saving measure: in 90% of cases, a life can be saved through early detection. In general, Duffy patients are navigating complex health issues, placing their focus on day-to-day ailments rather than preventive care. Through education and referrals from Duffy providers, early detection can have a major impact on the lives of the 37% of Duffy patients who are over the age of 50 and thus at higher risk for colorectal cancer.

The team leading this initiative is multidisciplinary, composed of staff from the medical department, population health and quality improvement teams, information technology, referrals, and case management. Aside from the completion of specific tasks related to the screening process, the team’s goal is to facilitate the process for Duffy patients, providing education, support around access, and other interventions, as needed.

While the COVID-19 pandemic caused a decline in screenings in 2020 and early 2021, over the last several months, the team saw increased rates month over month. As of June 2021, the rates for each measure by which Duffy Health Center is being evaluated were as follows (as compared to the learning collaborative’s goals): • At-home fecal immunochemical test completion rate: 33% (goal: 30%) • Colonoscopy completion rate: 24% (goal: 20%) • Follow-up colonoscopy rate: 31% (goal: 15%) • Overall colorectal cancer screening rate: 32% (goal: 50%) In the Summer of 2021, Duffy Health Center hosted a medical student who created a workplan focused on easing patients’ access at each step of the referral process. With the implementation of these process improvements, the team looks forward to creating a sustainable workflow that will be accessible from a patient-centered perspective and move the dial even further on our screening rates.

Patient Education & Care Management: Diabetes In general, the population served

by Duffy Health Center - those who are experiencing or are at risk of homelessness - have a disproportionate rate of uncontrolled diabetes compared to the general public. This is due to an abundance of medical complexities and co-existing chronic conditions.

Supporting patients in managing diabetes is one of the top priorities for the Duffy team. Prior to COVID-19, our population health and chronic disease management staff worked closely with the medical team to offer in-person educational sessions and facilitate group support in order to encourage better outcomes for this subset of patients. The COVID-19 pandemic altered the level of support we were able to provide to diabetic patients as we were unable to gather them in a group setting.

Despite the setbacks of the pandemic, the work on this initiative did not stop. The team used the time to work on their “wish list” items, including drafting a new set of educational documents and slowly re-building the program with the support of one of our Registered Nurses. They are now using these tools to rebuild the program, starting with diabetes education visits with a subset of patients one Nurse Practitioner and conducting a PDSA (“Plan-Do-Study-Act”) before branching out to additional Duffy providers.

Eventually, all Duffy primary care providers will have the tools to provide diabetes management education and care to make an even greater impact on diabetes care for our patients.

Community Partnership: Treating Substance Use Disorders During the COVID-19 pandemic, communities around the country saw an increase in substance use, and ours was no different. Feelings of uncertainty, isolation, and hopelessness were universal, and especially impacted individuals with substance use disorders; those active in their use, as well as those in sustained recovery.

In response to the increased need for substance use disorder services in our community, Duffy Health Center has been working collaboratively with the Community Health Center of Cape Cod (CHCCC) and the AIDS Support Group of Cape Cod (ASGCC) as part of the HEALing Communities Study. The study is part of the HEAL Initiative funded by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA), aimed at testing the integration of prevention, overdose treatment, and medication-based treatment in targeted communities.

In FY21, this collaboration brought the CHART (Community Harm Reduction and Treatment) Team (pictured below). The team, which includes a Harm Reduction Specialist and Recovery Support Navigators, is based out of a mobile clinic that travels throughout the targeted service areas of Bourne and Sandwich multiple days per week. They provide harm reduction services including connection to telehealth appointments for medications for opioid use disorder, same-day access to prescriptions, access to overdose prevention education, and naloxone distribution.

The goal of the program is to meet people in the communities where they live and work in order to remove barriers to engagement, including time and transportation, but also the sense of intimidation that many feel walking into an establishment that offers treatment.

The CHART Team provides brief, immediate interventions as a first step in engaging - and building trust - with individuals struggling with substance use.

Strategic Planning: Goals for 2022 through 2024 The Duffy Health Center team excels at creating trusting relationships with the most marginalized persons in our community; these relationships, in turn, facilitate the provision of care for the whole person.

Getting the “Duffy House” In Order

Expanding Our Programs & Our Reach

• Resource alignment to sustain operations

• New programs to respond to Duffy patients’ needs

• New tools for effective patient engagement

• New programs to expand our impact

Developing Our Workforce

Responding to Community Needs

Workforce development in quality improvement, safety, and diversity, equity & inclusion.

Identifying and responding to gaps in community services.

$9,754 raised this year by the 28 members of Duffy’s monthly giving circle, the Community of Hope, an increase of 50% since last year. Help us grow even more.

Click to make an impact with a monthly gift.

Community leaders Lisa Oliver, President, CEO & Chairman at The Cooperative Bank of Cape Cod and Dan Wolf, Founder & CEO of CapeAir, share why they support the mission of Duffy Health Center.

Click the image to play!

Revenue FY 2021 Revenue Actual Fiscal Year 2021 Net Patient Service Revenue 3,547,515 Grant Revenue 5,176,922 Program Revenue 232,582 Donations & Special Events 292,964 Other Income 1,266,566 -----------------------------------------------------------------------TOTAL 10,516,549

292,964 232,582

1,266,566 3,547,515

5,176,922

Fiscal Year 2020 Net Patient Service Revenue 3,760,001 Grant Revenue 3,919,898 Program Revenue 231,815 Donations & Special Events 214,079 Other Income 1,684,100 -----------------------------------------------------------------------TOTAL 9,809,893

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

Expenses Fiscal Year 2021 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

207,237

737,996

FY 2021 Expense Actual

96,081 70,798 122,299 271,663

Salaries and Wages Taxes and Fringe Contracted Services

510,378

Occupancy Client Expenses

405,567 5,530,542 1,290,980

Supplies & Minor Equipment Office Expense Bad Debt Depreciation Expense Other Expenses

128,896

Fiscal Year 2020 Salaries and Wages 5,492,466 Taxes and Fringe 1,190,933 Contracted Services 496,620 Occupancy 510,712 Client Expenses 259,674 Supplies & Minor Equipment 181,699 Office Expense 54,447 Bad Debt 128,896 Depreciation Expense 181,151 Other Expenses 370,552 ------------------------------------------------------------TOTAL 8,867,150

54,447

181,151 370,552

FY 2020 Expense Actual

181,699

Salaries and Wages

259,674

Taxes and Fringe

510,712

Contracted Services Occupancy 496,620 1,190,933

Client Expenses 5,492,466

Supplies & Minor Equipment Office Expense Bad Debt Depreciation Expense Other Expenses

Thank you for your support of our mission.

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* The flags on the front lawn in the cover photo acknowledge Substance Use Disorder Recovery Month, September 2021.