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TEDMED 2012

Rebecca Onie: What if our healthcare system kept us healthy?

April 11, 2012

Rebecca Onie asks audacious questions: What if waiting rooms were a place to improve daily health care? What if doctors could prescribe food, housing and heat in the winter? At TEDMED she describes Health Leads, an organization that does just that -- and does it by building a volunteer base as elite and dedicated as a college sports team.

Rebecca Onie - Health services innovator
Rebecca Onie is the founder of Health Leads, a program that connects patients to basic care and resources, such as food and housing, that are the root cause of many health problems. Full bio

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Double-click the English subtitles below to play the video.
So my freshman year of college
00:15
I signed up for an internship in the housing unit
00:17
at Greater Boston Legal Services.
00:20
Showed up the first day
00:22
ready to make coffee and photocopies,
00:23
but was paired with this righteous, deeply inspired attorney
00:26
named Jeff Purcell,
00:30
who thrust me onto the front lines
00:32
from the very first day.
00:34
And over the course of nine months
00:36
I had the chance
00:38
to have dozens of conversations
00:39
with low-income families in Boston
00:41
who would come in presenting with housing issues,
00:44
but always had an underlying health issue.
00:47
So I had a client who came in,
00:50
about to be evicted because he hasn't paid his rent.
00:52
But he hasn't paid his rent, of course,
00:54
because he's paying for his HIV medication
00:57
and just can't afford both.
00:59
We had moms who would come in,
01:01
daughter has asthma,
01:03
wakes up covered in cockroaches every morning.
01:04
And one of our litigation strategies
01:07
was actually to send me into the home of these clients
01:09
with these large glass bottles.
01:12
And I would collect the cockroaches,
01:14
hot glue-gun them to this poster board
01:16
that we'd bring to court for our cases.
01:19
And we always won
01:21
because the judges were just so grossed out.
01:22
Far more effective, I have to say,
01:25
than anything I later learned in law school.
01:27
But over the course of these nine months,
01:30
I grew frustrated with feeling
01:33
like we were intervening too far downstream
01:34
in the lives of our clients --
01:37
that by the time they came to us,
01:40
they were already in crisis.
01:41
And at the end of my freshman year of college,
01:44
I read an article about the work
01:46
that Dr. Barry Zuckerman was doing
01:48
as Chair of Pediatrics
01:50
at Boston Medical Center.
01:52
And his first hire was a legal services attorney
01:53
to represent the patients.
01:56
So I called Barry,
01:58
and with his blessing, in October 1995
02:00
walked into the waiting room
02:02
of the pediatrics clinic at Boston Medical Center.
02:05
I'll never forget,
02:07
the TVs played this endless reel of cartoons.
02:09
And the exhaustion of mothers
02:12
who had taken two, three, sometimes four buses
02:15
to bring their child to the doctor
02:18
was just palpable.
02:20
The doctors, it seemed,
02:22
never really had enough time for all the patients,
02:23
try as they might.
02:25
And over the course of six months,
02:26
I would corner them in the hallway
02:27
and ask them a sort of naive but fundamental question:
02:29
"If you had unlimited resources,
02:33
what's the one thing you would give your patients?"
02:35
And I heard the same story again and again,
02:39
a story we've heard hundreds of times since then.
02:41
They said, "Every day we have patients that come into the clinic --
02:44
child has an ear infection,
02:48
I prescribe antibiotics.
02:49
But the real issue is there's no food at home.
02:51
The real issue
02:54
is that child is living with 12 other people
02:56
in a two-bedroom apartment.
02:58
And I don't even ask about those issues
02:59
because there's nothing I can do.
03:01
I have 13 minutes with each patient.
03:04
Patients are piling up in the clinic waiting room.
03:06
I have no idea where the nearest food pantry is.
03:08
And I don't even have any help."
03:11
In that clinic, even today,
03:13
there are two social workers
03:15
for 24,000 pediatric patients,
03:16
which is better than a lot of the clinics out there.
03:19
So Health Leads was born of these conversations --
03:22
a simple model
03:25
where doctors and nurses
03:26
can prescribe nutritious food,
03:28
heat in the winter
03:30
and other basic resources for their patients
03:31
the same way they prescribe medication.
03:34
Patients then take their prescriptions
03:36
to our desk in the clinic waiting room
03:38
where we have a core of well-trained college student advocates
03:41
who work side by side with these families
03:45
to connect them out
03:47
to the existing landscape of community resources.
03:48
So we began with a card table in the clinic waiting room --
03:52
totally lemonade stand style.
03:55
But today we have a thousand college student advocates
03:57
who are working to connect nearly 9,000 patients and their families
04:01
with the resources that they need to be healthy.
04:05
So 18 months ago
04:08
I got this email that changed my life.
04:10
And the email was from Dr. Jack Geiger,
04:12
who had written to congratulate me on Health Leads
04:15
and to share, as he said,
04:18
a bit of historical context.
04:19
In 1965 Dr. Geiger founded
04:22
one of the first two community health centers in this country,
04:25
in a brutally poor area in the Mississippi Delta.
04:28
And so many of his patients came in
04:31
presenting with malnutrition
04:33
that be began prescribing food for them.
04:36
And they would take these prescriptions to the local supermarket,
04:38
which would fill them
04:41
and then charge the pharmacy budget of the clinic.
04:42
And when the Office of Economic Opportunity in Washington, D.C. --
04:45
which was funding Geiger's clinic --
04:48
found out about this,
04:50
they were furious.
04:51
And they sent this bureaucrat down
04:52
to tell Geiger that he was expected to use their dollars
04:54
for medical care --
04:57
to which Geiger famously and logically responded,
04:58
"The last time I checked my textbooks,
05:02
the specific therapy for malnutrition was food."
05:04
(Laughter)
05:09
So when I got this email from Dr. Geiger,
05:10
I knew I was supposed to be proud
05:13
to be part of this history.
05:15
But the truth is
05:17
I was devastated.
05:18
Here we are,
05:20
45 years after Geiger has prescribed food for his patients,
05:21
and I have doctors telling me,
05:25
"On those issues, we practice a 'don't ask, don't tell' policy."
05:27
Forty-five years after Geiger,
05:31
Health Leads has to reinvent
05:34
the prescription for basic resources.
05:35
So I have spent hours upon hours
05:38
trying to make sense of this weird Groundhog Day.
05:41
How is it that if for decades
05:45
we had a pretty straightforward tool for keeping patients,
05:47
and especially low-income patients, healthy,
05:50
that we didn't use it?
05:52
If we know what it takes to have a healthcare system
05:54
rather than a sick-care system,
05:57
why don't we just do it?
06:00
These questions, in my mind,
06:02
are not hard because the answers are complicated,
06:04
they are hard because they require that we be honest with ourselves.
06:07
My belief is that it's almost too painful
06:12
to articulate our aspirations for our healthcare system,
06:16
or even admit that we have any at all.
06:19
Because if we did,
06:22
they would be so removed
06:23
from our current reality.
06:24
But that doesn't change my belief
06:26
that all of us, deep inside,
06:29
here in this room and across this country,
06:32
share a similar set of desires.
06:36
That if we are honest with ourselves
06:39
and listen quietly,
06:41
that we all harbor
06:43
one fiercely held aspiration for our healthcare:
06:45
that it keep us healthy.
06:49
This aspiration that our healthcare keep us healthy
06:51
is an enormously powerful one.
06:55
And the way I think about this
06:57
is that healthcare is like any other system.
07:00
It's just a set of choices that people make.
07:02
What if we decided
07:04
to make a different set of choices?
07:06
What if we decided to take all the parts of healthcare
07:09
that have drifted away from us
07:12
and stand firm and say, "No.
07:14
These things are ours.
07:16
They will be used for our purposes.
07:18
They will be used to realize
07:20
our aspiration"?
07:22
What if everything we needed
07:24
to realize our aspiration for healthcare
07:26
was right there in front of us
07:28
just waiting to be claimed?
07:29
So that's where Health Leads began.
07:31
We started with the prescription pad --
07:33
a very ordinary piece of paper --
07:35
and we asked, not what do patients need to get healthy --
07:37
antibiotics, an inhaler, medication --
07:41
but what do patients need to be healthy,
07:44
to not get sick in the first place?
07:47
And we chose to use the prescription
07:50
for that purpose.
07:52
So just a few miles from here
07:53
at Children's National Medical Center,
07:55
when patients come into the doctor's office,
07:56
they're asked a few questions.
07:59
They're asked, "Are you running out of food at the end of the month?
08:00
Do you have safe housing?"
08:03
And when the doctor begins the visit,
08:05
she knows height, weight, is there food at home,
08:07
is the family living in a shelter.
08:09
And that not only leads to a better set of clinical choices,
08:11
but the doctor can also prescribe those resources for the patient,
08:14
using Health Leads like any other sub-specialty referral.
08:18
The problem is,
08:22
once you get a taste of what it's like
08:24
to realize your aspiration for healthcare,
08:26
you want more.
08:28
So we thought,
08:30
if we can get individual doctors
08:31
to prescribe these basic resources for their patients,
08:32
could we get an entire healthcare system
08:35
to shift its presumption?
08:38
And we gave it a shot.
08:41
So now at Harlem Hospital Center
08:42
when patients come in with an elevated body mass index,
08:44
the electronic medical record
08:47
automatically generates a prescription for Health Leads.
08:49
And our volunteers can then work with them
08:53
to connect patients to healthy food and excercise programs
08:54
in their communities.
08:58
We've created a presumption
08:59
that if you're a patient at that hospital
09:00
with an elevated BMI,
09:02
the four walls of the doctor's office
09:03
probably aren't going to give you everything
09:06
you need to be healthy.
09:07
You need more.
09:09
So on the one hand,
09:10
this is just a basic recoding
09:11
of the electronic medical record.
09:12
And on the other hand,
09:14
it's a radical transformation
09:16
of the electronic medical record
09:18
from a static repository of diagnostic information
09:20
to a health promotion tool.
09:24
In the private sector,
09:26
when you squeeze that kind of additional value
09:28
out of a fixed-cost investment,
09:30
it's called a billion-dollar company.
09:32
But in my world,
09:34
it's called reduced obesity and diabetes.
09:36
It's called healthcare --
09:39
a system where doctors can prescribe solutions
09:41
to improve health,
09:44
not just manage disease.
09:46
Same thing in the clinic waiting room.
09:48
So every day in this country
09:49
three million patients
09:51
pass through about 150,000 clinic waiting rooms in this country.
09:52
And what do they do when they're there?
09:57
They sit, they watch the goldfish in the fish tank,
09:59
they read extremely old copies
10:02
of Good Housekeeping magazine.
10:05
But mostly we all just sit there forever, waiting.
10:07
How did we get here
10:10
where we devote hundreds of acres and thousands of hours
10:12
to waiting?
10:15
What if we had a waiting room
10:17
where you don't just sit when you're sick,
10:18
but where you go to get healthy.
10:20
If airports can become shopping malls
10:22
and McDonald's can become playgrounds,
10:25
surely we can reinvent the clinic waiting room.
10:28
And that's what Health Leads has tried to do,
10:31
to reclaim that real estate and that time
10:33
and to use it as a gateway
10:35
to connect patients
10:37
to the resources they need to be healthy.
10:38
So it's a brutal winter in the Northeast,
10:41
your kid has asthma, your heat just got turned off,
10:42
and of course you're in the waiting room of the ER,
10:45
because the cold air triggered your child's asthma.
10:47
But what if instead of waiting for hours anxiously,
10:49
the waiting room became the place
10:52
where Health Leads turned your heat back on?
10:54
And of course all of this requires
10:57
a broader workforce.
10:58
But if we're creative, we already have that too.
11:00
We know that our doctors and nurses
11:04
and even social workers
11:06
aren't enough,
11:07
that the ticking minutes of health care
11:09
are too constraining.
11:10
Health just takes more time.
11:12
It requires a non-clinical army
11:14
of community health workers and case managers
11:17
and many others.
11:19
What if a small part of that next healthcare workforce
11:21
were the 11 million college students in this country?
11:24
Unencumbered by clinical responsibilities,
11:28
unwilling to take no for an answer
11:31
from those bureaucracies
11:33
that tend to crush patients,
11:35
and with an unparalleled ability
11:37
for information retrieval
11:39
honed through years of using Google.
11:40
Now lest you think it improbable
11:43
that a college volunteer
11:46
can make this kind of commitment,
11:47
I have two words for you:
11:49
March Madness.
11:51
The average NCAA Division I men's basketball player
11:53
dedicates 39 hours a week to his sport.
11:57
Now we may think that's good or bad,
12:00
but in either case it's real.
12:02
And Health Leads is based on the presumption
12:05
that for too long
12:07
we have asked too little of our college students
12:09
when it comes to real impact in vulnerable communities.
12:11
College sports teams say,
12:15
"We're going to take dozens of hours
12:16
at some field across campus at some ungodly hour of the morning
12:18
and we're going to measure your performance, and your team's performance,
12:22
and if you don't measure up or you don't show up,
12:25
we're going to cut you off the team.
12:27
But we'll make huge investments
12:29
in your training and development,
12:31
and we'll give you an extraordinary community of peers."
12:32
And people line up out the door
12:35
just for the chance to be part of it.
12:37
So our feeling is,
12:40
if it's good enough for the rugby team,
12:41
it's good enough for health and poverty.
12:42
Health Leads too recruits competitively,
12:45
trains intensively,
12:48
coaches professionally,
12:49
demands significant time,
12:51
builds a cohesive team
12:53
and measures results --
12:55
a kind of Teach for America for healthcare.
12:56
Now in the top 10 cities in the U.S.
12:59
with the largest number of Medicaid patients,
13:01
each of those has at least 20,000 college students.
13:03
New York alone has half a million college students.
13:06
And this isn't just a sort of short-term workforce
13:10
to connect patients to basic resources,
13:13
it's a next generation healthcare leadership pipeline
13:15
who've spent two, three, four years
13:18
in the clinic waiting room
13:21
talking to patients about their most basic health needs.
13:22
And they leave with the conviction,
13:26
the ability and the efficacy
13:28
to realize our most basic aspirations for health care.
13:30
And the thing is, there's thousands of these folks already out there.
13:34
So Mia Lozada is Chief Resident of Internal Medicine
13:37
at UCSF Medical Center,
13:41
but for three years as an undergraduate
13:42
she was a Health Leads volunteer
13:44
in the clinic waiting room at Boston Medical Center.
13:46
Mia says, "When my classmates write a prescription,
13:49
they think their work is done.
13:53
When I write a prescription,
13:55
I think, can the family read the prescription?
13:56
Do they have transportation to the pharmacy?
13:59
Do they have food to take with the prescription?
14:01
Do they have insurance to fill the prescription?
14:03
Those are the questions I learned at Health Leads,
14:06
not in medical school."
14:08
Now none of these solutions --
14:10
the prescription pad, the electronic medical record,
14:12
the waiting room,
14:15
the army of college students --
14:16
are perfect.
14:17
But they are ours for the taking --
14:18
simple examples
14:21
of the vast under-utilized healthcare resources
14:22
that, if we reclaimed and redeployed,
14:26
could realize our most basic aspiration
14:29
of healthcare.
14:32
So I had been at Legal Services for about nine months
14:34
when this idea of Health Leads started percolating in my mind.
14:37
And I knew I had to tell Jeff Purcell, my attorney,
14:40
that I needed to leave.
14:43
And I was so nervous,
14:44
because I thought he was going to be disappointed in me
14:45
for abandoning our clients for some crazy idea.
14:48
And I sat down with him and I said,
14:51
"Jeff, I have this idea
14:53
that we could mobilize college students
14:55
to address patients' most basic health needs."
14:57
And I'll be honest,
15:00
all I wanted was for him to not be angry at me.
15:02
But he said this,
15:05
"Rebecca, when you have a vision,
15:06
you have an obligation to realize that vision.
15:10
You must pursue that vision."
15:14
And I have to say, I was like "Whoa.
15:17
That's a lot of pressure."
15:20
I just wanted a blessing,
15:22
I didn't want some kind of mandate.
15:23
But the truth is
15:25
I've spent every waking minute nearly since then
15:26
chasing that vision.
15:29
I believe that we all have a vision
15:31
for healthcare in this country.
15:34
I believe that at the end of the day
15:36
when we measure our healthcare,
15:38
it will not be by the diseases cured,
15:40
but by the diseases prevented.
15:43
It will not be by the excellence of our technologies
15:45
or the sophistication of our specialists,
15:48
but by how rarely we needed them.
15:51
And most of all,
15:54
I believe that when we measure healthcare,
15:55
it will be, not by what the system was,
15:58
but by what we chose it to be.
16:00
Thank you.
16:03
(Applause)
16:04
Thank you.
16:15
(Applause)
16:16
Translator:Timothy Covell
Reviewer:Morton Bast

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Rebecca Onie - Health services innovator
Rebecca Onie is the founder of Health Leads, a program that connects patients to basic care and resources, such as food and housing, that are the root cause of many health problems.

Why you should listen

In 1996, as a sophomore in college, Rebecca Onie had a realization: The health care system in the United States was not set up to diagnose nor treat the socioeconomic issues that lead to poor health, and that health care providers are not given tools to address basic problems like nutrition and housing.

So, while still a sophomore, she co-founded Health Leads, a program that assists low-income patients and their families to access food, heat, and other basic resources they need to be healthy. With the additional insight that college volunteers could be recruited and trained into an elite group just like a college sport team, she found the people and skills needed to produce such an audacious idea. Since then it has grown tremendously, and now operates in Baltimore, Boston, Chicago, New York, Providence, and Washington, DC, and in the last year assisted over 8,800 patients.

In 2009, Rebecca was awarded a MacArthur “Genius” Fellowship.

Photo: Courtesy of the John D. & Catherine T. MacArthur Foundation

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