In 2008, Mayor Thomas M. Menino convened a summit of Boston’s leading healthcare, academic, policy, and community leaders to address primary care access in the city. As a result of that summit, Mayor Menino formed the Mayor’s Task Force on Improving Access to Primary Care in Boston, which created a set of recommendations that have served as a roadmap to increase access, improve quality, and integrate public health efforts with the primary care system.

Since 2010, the Mayoral Prize for Innovations in Primary Care has recognized Boston-based organizations that are transforming the primary care landscape and improving our city’s health in three settings – Healthcare, the Community, and the Workplace. As Mayor Thomas M. Menino’s tenure concludes, we catch up with past winners to learn not only what the Mayoral Prize has meant to them, but also to learn what further achievements they have made since accepting the award.

Founded in 1974 as a two-room clinic apartment in Allston, the Joseph M. Smith Community Health Center (JMSCHC) has evolved into an independent health center with five clinical sites in Allston-Brighton and Waltham. The health center provides a diverse array of primary care services and specialized care provisions while offering comprehensive support services in patient care management.

JMSCHC also provides two school-based sites that offer comprehensive health services and education, spanning their reach to over 12,000 patients in 15 different languages.

In 2011, the JMSCHC was awarded the Mayoral Prize for Primary Care Innovation in a Healthcare Setting for their unique and successful Prevention and Wellness (P&W) Healthcare Maintenance program, a care coordination model that uses Health Information Technology (HIT) and care navigators to offer culturally sensitive and language-appropriate care, coordination, and case management services to diverse patients.

As the program grew, it evolved into a customizable Electronic Medical Record (EMR) system, which combined all health screening information in one location. Thanks to this new technology, providers could more easily view patients scheduled and completed screenings, allowing them to make appropriate follow-up care decisions.

Just within the first year of the P&W implementation, JMSCHC saw remarkable improvements in patient screening rates, with a 152% increase in the number of patients receiving colonoscopies. 94% of all eligible female patients received a Pap test in 2010, a significant increase from 89% in 2009. Their success continued with over 1,000 mammograms, 1,550 Pap tests, and 270 colonoscopies in 2010.

Since winning the Mayoral Prize, JMSCHC has achieved recognition from the National Committee for Quality Assurance (NCQA), being awarded the Level 2 Patient Centered Medical Home honor in March 2013. They also received funding from the MA eHealth Institute (MAeHI) to pilot a direct exchange with Beth Israel Deaconess Medical Center (BIDMC) through the MassHIway Health Information Exchange (HIE) in an ongoing effort to enhance existing care coordination. Through collaboration between BIDMC and Nextgen, JMSCHC will soon be able to receive all physicians’ written diagnoses and treatment recommendations electronically, further streamlining the referral process. The Prevention and Wellness platform has also been updated, adding more features that allow providers to review and include necessary follow-up visits and referrals in one central location.

Winning the Mayoral Prize led to the development of several new initiatives, including the hiring of a complex care manager for each of JMSCHC’s clinical sites. The award also garnered recognition from grant sponsors and lenders for a new building project. JMSCHC continues to show positive results from its P&W program, with increases in patients being active in their cancer prevention care – coming to screenings well-prepared and cancelling their appointments less often.

As a result of winning the Prize, JMSCHC has gained increased recognition and for its ongoing efforts to enhance care coordination and patient self-care management, striving to provide patients with quality preventive health services that help reduce chronic disease and hospitalization. With 80% of JMSCHC’s patient population comprised of low-income, racially and ethnically diverse residents, and 53% of non-English speaking clients requiring services in a different language, the P&W has also made a significant impact in reducing health inequities, offering culturally competent care and efficient care coordination so that patients receive the support they need and are equipped to manage their own health.