Why are we waiting for them to come to us?”
The following year, the issue was raised again by Margaret Wagner, director of social services at Cleveland’s Association for the Crippled and Disabled, one of many philanthropic agencies in the City tending to the needs of those less fortunate. In a letter to Dudley S. Blossom, Director of Public Welfare overseeing City Hospital, Ms. Wagner criticized City Hospital for regularly discharging indigent patients with little more than the clothes on their backs and little sense of how to receive adequate follow-up care or find work. Those patients, Ms. Wagner wrote, ended up at private welfare agencies like hers. Their angst and suffering could be prevented, she said, if City Hospital would hire social workers.
Mr. Blossom not only agreed, he hired Ms. Wagner as director of the new social work department. “The acknowledgement that there could be a relationship between illness and emotional and psychological factors,” she later explained, was a core principle of her department. “Social service added another dimension to the practice of medicine.”2
Whether called by that name or not, social service has been at the heart of MetroHealth since the day it was founded. In 1837, its first year in existence, City Hospital staff delivered “outdoor relief”—firewood, food, rent, and clothing—to the City’s poor. During the smallpox epidemic of 1901, a City Hospital physician directed crews with heavy sprayers and disinfectant to douse the homes of the sick and, later, every home in the city, to protect public health. Basic needs were top of mind for Howell Wright when—in his role as superintendent of City Hospital in 1914—he wrote of the importance of nonmedical care: “A City Hospital of today above all, it must, through its social service work and through co-operation with all other community social agencies, give a watchfulness over public health and results that are more days of life, work and happiness to its citizens.”3
Today, the medical community understands that the social determinants of health—which include the food we eat, air we breathe, homes we live in, jobs we work—account for 80 percent of a person’s health. History tells us that the bridge from the delivery of outdoor relief in the 19th century to addressing the social determinants of health in the 21st century was built by social workers. And they made their biggest impact in times of need.
At City Hospital, care officially designated as social work began with Ms. Wagner. It continued in the 1930s, when City Hospital distributed food during the Great Depression; in the 1970s, after unrest in Cleveland’s neighborhoods led to the creation of the Golden Age Outreach for Health Program, which sent volunteers to monitor the health and well-being of underserved senior citizens; and in the 1990s—under the leadership of Judith Ross, then Director of Social Work, and Mark Lehman, a newly hired Social Work Manager at MetroHealth—to help Clevelanders living with HIV during the rise of the AIDS epidemic. Ahead of her time, Ms. Ross predicted the critical role that social work case management could play in the successful management of the disease.
Mr. Lehman grew up in Northeast Ohio, attended Ohio State University and Case Western Reserve University, and, from 1975 to 1992, worked at Cleveland’s St. Vincent Charity Hospital. He started there as a social worker in general medicine and, by 1984, had joined a volunteer group of gay men and lesbians working on healthcare issues in the gay community. Quickly, the group’s focus narrowed to HIV and AIDS and became the Health Issues Task Force (HITF), with Mr. Lehman overseeing all the support services it provided.4
Taking cues from the Gay Men’s Health Crisis in New York, Mr. Lehman set up a buddy program for people with HIV, who often were turned out by their families. He also set up support networks for HIV patients who needed housing or who struggled with mental health issues, and another group for the buddies themselves. So it made sense that he would end up at MetroHealth in 1992, the year after it opened its HIV clinic.
As HIV numbers rose, the patients’ needs increased, too. At MetroHealth, social workers were the essential backbone of the HIV program, ensuring that those living with HIV had places to live, received the counseling they needed, made it to their appointments, took their medication, and stayed healthy. Mr. Lehman wanted to ensure those services continued and, in 1998, he applied for a federal Ryan White grant—named for a teen who died after contracting AIDS from a blood transfusion. That grant brought hundreds of thousands of dollars to the health system, enough to pay salaries and benefits for a handful of social workers and nurses. It also required Mr. Lehman to prove that social work was making a difference in the lives of HIV patients. Observations by Robert Kalayjian, MD, the first director of the HIV clinic at MetroHealth, backed up those findings.5
Dr. Kalayjian documented that HIV patients who worked regularly with social workers were more likely to take their medication, decreasing the chances that the virus would mutate. They needed fewer hospital stays and made fewer visits to the Emergency Department. The social workers were so successful, in fact, that grant administrators offered MetroHealth additional funding.6
“It showed the power of social work and what social work can bring to the medical setting to really help patients have more success with their medical care,” Mr. Lehman said. “It was the doctor-nurse-social work combination that kept people on track, on their medication, on their regimen, in the clinic, getting blood work done.
“The fact that you were able to do this for patients took HIV from a fatal illness for some to a chronic illness that could be managed. People who might have passed away in the past now had a safety net.”7
In 2018, Mr. Lehman retired from MetroHealth and Jason McMinn and Jennifer McMillen-Smith kept the HIV Social Work program strong. In 2022, MetroHealth continued to be the largest provider of HIV care in the Cleveland area, serving approximately 1,900 patients, with help from 11 social workers dedicated to their care. And all those years later, the Ryan White grant money was still coming in, still paying for social workers, still changing—and saving—lives.
“Social workers have always looked at the social determinants of health,” Mr. Lehman said. “We’ve looked at mental health, housing, domestic violence, substance abuse—all those things that can complicate someone’s life. This is why social workers should be in hospitals. People don’t just have medical problems; they have other issues in their lives.”8
“It showed the power of social work and what social work can bring to the medical setting to really help patients have more success with their medical care.”
“Why are we waiting for them to come to us?”
That’s the question Christine Alexander, MD, MetroHealth’s Chair of Family Medicine, asked in 2009 after reviewing data from the previous ten years that showed a plunge in the number of children coming to MetroHealth for well visits—visits that include lead screenings and immunizations against measles, mumps, and other childhood diseases.9
When she took her findings to her colleagues in pediatrics, Robert Needlman, MD, offered up some additional data. His numbers showed that 80 percent of students in the Cleveland Metropolitan School District (CMSD) relied on MetroHealth for their care. But more and more of that care was being provided in urgent care centers or the Emergency Department when children were sick, instead of in their doctors’ offices during routine well checks. As a result, children slipped behind on their immunizations and things like prescriptions for asthma or diabetes. For Dr. Alexander, one thing was clear: the students were not to blame.
“We’re the primary care providers for those kids, which means we’re responsible for their healthcare, right?” she said. “We’re signing up to take care of the kids and we clearly weren’t reaching them.”
Just as clear was the solution: she had to take healthcare into the schools.
“For me, it was all about these children out there that needed and deserved care and they weren’t getting it. . . . That really was the birth of the program—our realizing that we were failing these kids. We were waiting for them to come to us. And they weren’t getting here.”
The problem, she realized quickly, was an issue of access. Parents didn’t always have transportation, or they were working two jobs and couldn’t get to the doctor’s office between 9:00 and 5:00 on weekdays, or they couldn’t afford to take time off work and have their paychecks docked. Dr. Alexander knew how illness affected attendance, how attendance affected success in school, how success in school affected success in life—and health. And she wasn’t about to let access get in the way of these children’s futures.10
Bureaucracy did instead.
CMSD had an interim superintendent at the time. Teachers, nurses, administrators, and the union all needed to weigh in. Building health clinics in schools meant requesting bids, waiting for them to come in, reviewing them. And then there was the question of how the care would be paid for.
In the middle of trying to wrangle those
issues, Mound STEM Elementary School in Cleveland’s Slavic Village neighborhood offered MetroHealth a classroom that could be converted into an exam room. Dr. Alexander and her team went to work mounting dividers and bringing in white-noise machines to ensure privacy. With donations from nearly two dozen individuals, corporations, and foundations, they opened their first clinic inside a school in the fall of 2013.11
Knowing high school students needed care, too, she went next to Lincoln-West High School, not far from MetroHealth’s main campus. And she didn’t let the lack of space there stop her. Instead, she contacted the City’s public health department and reserved a public health van—an exam room on wheels—one day a week and kicked off a mobile version of her pilot project.
Frustrated that she couldn’t provide care to more students in more schools, Dr. Alexander talked with the health system’s new President and CEO, Dr. Akram Boutros, who arrived at MetroHealth in June 2013.
“We need our own mobile unit,” he told Dr. Alexander. “We’ll take our own clinic on wheels to the students.”
“That’s $1.2 million,” Dr. Alexander told him.
“We’re going to get the money,” he assured her. And he turned the task over to Kate Brown, head of The MetroHealth Foundation, the health system’s fundraising arm.12
“Now go find the money,” he told her. Starting in the fall of 2013, Ms. Brown and her staff did just that.13
Good news came in June 2014, when Ms. Brown called to say the money had been raised—enough to purchase a brand-new mobile health unit, large enough for two exam rooms, a waiting room, and a laboratory. That fall, the mobile unit hit the road, delivering care to 12 more CMSD schools: two high schools and ten elementary schools. That meant more children were not only getting immunizations, check-ups, sports physicals, and medication for chronic illnesses, they were also being screened for mental health issues.
From the first day, the School Health Program checked students’ mental as well as physical health, with MetroHealth psychologist Lisa Ramirez, PhD, at every school check-up. As the school health program expanded to more high schools in 2015, so did the mental health screenings. The chronic stress MetroHealth was seeing in students was confirmed not long after that when the US Centers for Disease Control released the results of its 2015 Youth Risk Behavior Survey. Of the 19 cities included in the study, Cleveland students reported the highest rate of feeling severely sad or depressed—36 percent—and was the only big-city school district with more than one in five students—20.7 percent—reporting that they had attempted suicide.
It was clear to Dr. Ramirez that Cleveland students needed a way to understand the anxiety, stress, and despair that were consuming them. Many of these students were experiencing childhood adversity, including chronic poverty, housing instability, and living with caregivers who had a mental illness or substance use disorder. Some of the children were still reeling from the 2014 police shooting death of Tamir Rice and were anxious about the 2017 kidnapping and murder of 14-year-old Alianna DeFreeze.
“They were dealing with a lot of heavy, heavy stressors that most children do not have to withstand in childhood,” said Dr. Ramirez. “What they needed, honestly, was a trusted adult to help them understand that their feelings were not the problem. They needed validation that what they were going through was really hard. We had to validate that there was nothing wrong with them, that they were reacting in the way any human would.”
In the middle of her work with the students, Dr. Ramirez attended a performance of local teens breakdancing and singing hip-hop lyrics they’d written. As fast as she could, she called Linda Jackson, MetroHealth’s Director of Arts in Medicine, and Advanced Public Health Nurse Katie Davis, School Health Program Director. Together, the three of them created a new program called SAFE, Students Are Free to Express.14
SAFE brought spoken-word artists, drummers, painters, and other artists of color—teaching artists who looked like the students and shared their experiences—into the classroom. Together, they began creating art.
“We know that the arts have psychological, physiological, and social benefits. There’s research and evidence behind the benefits for our health and well-being,” Ms. Jackson said. That research, she explained, shows that creating art lowers stress hormones, can help lower anxiety and depression, and helps us regulate our emotions.
“The arts create social connection,” Ms. Jackson said. “They bring humanity, they help us understand each other. They give us another way to communicate, especially when we can’t express our feelings or understand what we’re feeling."15
“It’s an antidote for adversity,” Dr. Ramirez said. “This lets kids hit the pause button on their toxic stress. It lets children be children.”16
The program, which began with ninth graders, later expanded to include tenth graders, juniors, and pre-kindergarteners, kindergarteners, and first-graders.
In 2022, SAFE continued a study of its effectiveness, which was launched two years earlier with a $250,000 donation from JoAnn and Bob Glick and expanded with $85,000 in support from the National Endowment for the Arts. As of 2022, the MetroHealth School Health Program had grown to serve more than a dozen schools, including 13 in the Cleveland Metropolitan School District, and the entire Cleveland Heights-University Heights School District.17
In spite of the pandemic, the program’s 2019–20 results were impressive. Of the 2,198 students at 15 schools enrolled in the School Health Program, 1,198 participated in the program (54.5 percent). Of those students, 67 percent were up-to-date on well-child exams, and 70 percent were up-to-date on their immunizations. Students participating in the School Health Program tallied 50 percent fewer visits to emergency departments than non-participating students. Those statistics tell us that students in the MetroHealth School Health Program are as up-to-date or more up-to-date on their healthcare than most children in Ohio.
In March 2022, the Ohio Department of Health awarded the program nearly $4.5 million—more than any other school health program in the state—to help expand services. The money will be used to increase primary care, behavioral health, and dental services in the Cleveland and Cleveland Heights-University Heights school districts, to pilot telehealth services, to provide more care coordination, and to build or renovate additional school clinics.18
“It’s a far cry from where we started with a repurposed classroom and a tattered van we borrowed from the city,” Dr. Alexander said. “I never dreamt Dr. Boutros would say yes to $1.2 million or that Kate Brown would so quickly find the funding. Now we’re landing multi-million-dollar funding streams and developing innovative models of care to keep the program growing. The sky is the limit and it’s what these kids deserve."19
On June 28, 2019, MetroHealth President and CEO Dr. Akram Boutros ended his annual meeting speech by asking the more than 400 people at the meeting to dream with him.
“[I]magine a better future,” he said. “A future where we do more than applaud medical care that’s administered after the fact. A future where we provide care and support before people get sick. A future where Cleveland is more than a great city for medicine. A future where we’re a great city for health.”
In that same speech, Dr. Boutros offered a way to reach that dream with the announcement of MetroHealth’s new Institute for H.O.P.E.™: Health, Opportunity, Partnership, and Empowerment.20
The Institute, he said, would remove obstacles and help people of all backgrounds stay healthy, not just physically but emotionally, educationally, and financially. It would do that by partnering with organizations to, among other things, distribute healthy food, secure safe housing, and provide job training that would lead to higher wages, all with the goal of making sure more people could live lives of opportunity, dignity, and hope.
At that meeting, Dr. Boutros also announced that Susan Fuehrer, the Director and CEO of the VA Northeast Ohio Healthcare System, would serve as President of the Institute beginning July 1, 2019. She was paired with James Misak, MD, the MetroHealth family medicine physician tapped to provide clinical guidance and serve as the Institute’s Chief Medical Officer. With each of them having more than 30 years’ experience, they knew quality medical care was essential. They also knew it was not enough. And together, they went to work.
From the very start, the Institute partnered with Cuyahoga Community College to provide interviewing, job-hunting, and other skills to those entering the workforce or looking to move up. It partnered with the Greater Cleveland Food Bank to distribute healthy food to schoolchildren in the summer and families throughout the year. It partnered with Cleveland nonprofit Digital C to provide low-cost or subsidized Internet service to those who either had no access to it or couldn’t afford it.
Another early objective was figuring out who needed help and what kind. To do that, the Institute for H.O.P.E.™ helped MetroHealth begin screening patients, asking if they had trouble paying their electric or water bills, for example, or if they were experiencing violence at home. The answers not only helped the Institute fine-tune services, they revealed that the most common concern was not lack of food or housing. It was loneliness. More than 45 percent of MetroHealth’s patients screened at high risk for social isolation. Knowing that social isolation is associated with higher rates of depression, anxiety, and suicide, the team created Calls for HOPE. That program trains volunteers to make kind, concerned weekly phone calls—“small talk with a purpose”—to those at risk.
The Institute was deep into all that work when COVID-19 struck. Quickly, the staff pivoted and began delivering fresh produce and other groceries, hand sanitizer, diapers, baby wipes, and other necessities to COVID patients, new moms, and those experiencing homelessness. In total, approximately 10,000 individuals and families received help from the Institute and generous donations from The MetroHealth Foundation’s Helping Hands Fund.
“Imagine a better future,” Dr. Akram Boutros said. “A future where we do more than applaud medical care that’s administered after the fact.”
MetroHealth’s new Institute for H.O.P.E.TM helps remove obstacles and helps people of all backgrounds stay healthy, not just physically but emotionally, educationally, and financially.
COVID also magnified problems for those without Internet service. Prior to the pandemic, US Census data ranked Cleveland the least digitally connected large city in the country, with more than 46 percent of Cleveland residents having no broadband home Internet access. In response, the Institute for H.O.P.E.™ team ramped up its work with Digital C. Marielee Santiago, the Institute’s Director of Transformative Knowledge and Education, worked alongside the nonprofit to help more than 160 residents of Scranton Castle public housing for seniors connect with friends, fellow church members, children, grandchildren, doctors, and other care providers while avoiding exposure to a virus that hit older adults, especially those who were chronically ill, harder than others. More than half of the Scranton Castle residents were dealing with one or more chronic conditions, making isolation, in some cases, a matter of life or death. By June of 2020, Digital C had installed an antenna on the apartment building’s roof; by August, residents had computers. Then, in masked one-on-one training sessions, staff from the Institute, Digital C, and the ASC3 Digital Literacy Training Center taught residents how to Zoom with family, “attend” religious services, play bingo with friends, find recipes and music on YouTube, and talk with their doctors and other healthcare providers using the online medical record system MyChart.
This was about more than lifting spirits.
Patients who screened at risk for social isolation were 23 percent more likely to have heart disease, 25 percent more likely to have COPD, and 27 percent more likely to have dementia. That kind of data collection and analysis is another upside of the Institute’s work. So is its partnership with Unite Us, an innovative technology company that created an electronic platform that allows MetroHealth to help patients like never before.
Instead of handing a patient a slip of paper with a phone number for an organization that provides food or helps find housing, for example, a member of the healthcare team generates an electronic referral on the Unite Us platform, which automatically alerts the appropriate social service agency. That agency then contacts the patient, not the other way around. When the patient receives the services he or she needs—literacy courses, for example, or a connection to local food assistance—that is reported back to the medical team. That way, MetroHealth doctors and other caregivers can make sure no one slips through the cracks.
“Seamless connections between healthcare and social services are essential to the work of improving health and building opportunity,” said Karen Cook, the Institute’s Director of Healthy Families and Thriving Communities. “Through Unite Ohio, and with the consent of our patients, we can now make direct connections to a wealth of community resources that serve the needs of our patients. What’s more, we’re able to receive real-time updates on those referrals and know when the patient’s needs have been successfully addressed.”
Other health systems in the area have followed MetroHealth in joining Unite Us, including St. Vincent Charity Medical Center, University Hospitals, and the Cleveland Clinic.
The Institute for H.O.P.E.™ has grown, too, with other MetroHealth programs, each addressing the social determinants of health, now under its umbrella. Those include the School Health Program, the Centers for Health Resilience and Trauma Recovery, Arts in Health, and Faith-Based Programs. And it will keep growing, Mrs. Fuehrer said.
“Our work needs to continue until everyone is empowered to live their healthiest life,” she said, “and that healthiest life includes so much more than medical care.21