Connecting the City’s Social Services to Help At-Risk Populations

A four-year-old Massachusetts program called the Chelsea Hub helps vulnerable populations by increasing communication among a range of local groups.

A meeting of the Chelsea Hub in Massachusetts.
The Chelsea Hub in Massachusetts works with families and individuals who may need services from more than one community agency. Photo courtesy of the Chelsea Police Department

In Chelsea, Massachusetts, police, medical providers, and social services groups have found a low-cost way to reduce crime in the city while simultaneously encouraging at-risk residents to get the help they need.

Their strategy? Talking to one other.

Called the Chelsea Hub, the initiative consists of a weekly meeting among dozens of organizations and agencies to jointly discuss and determine how to help troubled individuals. Instead of each group working in isolation, hub members are able to apply multivariate solutions to multivariate problems.

Take, for example, a Chelsea resident in her mid-20s who was homeless and had been struggling with opioid addiction. She was well known to police and had been bouncing between jail, the emergency room, and the streets, where she’d been assaulted.

When her case was finally discussed among hub members, representatives from the Department of Children and Families (DCF) said that the woman has an 8-year-old child but lost custody a few years ago. Mental health workers said that the woman previously received mental health services, but stopped coming to their offices two years ago. Employees from a local soup kitchen added that they saw her there on a regular basis. And outreach workers who’d encountered her on the streets said she was desperate to get her child back.

Together, staff members from all of those organizations hatched a plan. They had some ideas about where to find the woman, and “all of a sudden we’re able to dangle a carrot in front of her, not just the stick,” says Dan Cortez, a community engagement specialist with the Chelsea Police Department, who gave this example. The hub’s outreach workers found the woman the next day and explained that they could probably get her into detox right away if she really was interested in eventually regaining custody of her child.

The woman took the outreach workers up on their offer. “Two weeks later, she’s in a residential program and is very excited about the prospect of visitation rights [with her child],” says Cortez. “She’s getting mental health counseling; she says she never felt supported before, that she always felt she had a problem, not a disease.”

It’s a success story—one that’s wholly due to amplified communication and cooperation among groups working with overlapping populations. Silo-busting, that is.

The hub model originated around 2011 in Prince Albert, a city in the Canadian province of Saskatchewan. It was adapted from a Scottish program and standardized, and had an almost immediate effect on the small city: in the first two years after its implementation, the rate of violent crime in Prince Albert dropped by 42 percent, says Brent Kalinowski, a former Prince Albert police officer who helped create the program. And between 2011 and 2014, the program saved the city’s police department roughly $3.2 million.

The concept was obviously groundbreaking, and has since spread to about 100 other locations in Canada. “We all agree, this is the biggest innovation we’ve seen in our lifetime,” says Kalinowski; he now travels all over Canada and the U.S. to promote the hub and affiliated policies.

Bringing the Hub to Chelsea

It was Kalinowski and his partners who brought the hub to Chelsea. The director of Roca, a Chelsea organization that works with at-risk youth, had heard about the hub and invited Kalinowski and others to come and explain it.

It was clear that Chelsea needed a new approach. A city of about 40,000 people directly abutting Boston, it had a high rate of violent crime and was listed in 2014 as the most dangerous city in Massachusetts. Despite its small size, it was also No.11 on a 2014 list of the country’s 100 most dangerous cities. Prior to the hub, residents who could potentially benefit from social services often fell through the cracks due to a lack of communication among related organizations.

Members of the Chelsea Hub gather weekly.
Hub partners gather at a weekly roundtable. Photo courtesy of the Chelsea Police Department

“Back in the old days, we had to say a Hail Mary and hope kids would get connected to [services] they needed; usually they didn’t,” explains Jason Owens, an assistant director with Roca who’s now the organization’s representative at hub meetings. When the Chelsea organizations heard about the Canadian hub, he says, “everyone went nuts: ‘Why haven’t we been doing this?’”

After the visit by Kalinowski and his colleagues, key organizations in Chelsea created a steering group to figure out how to launch their own hub. “Eventually, we said, ‘Let’s just do a pilot,’” explains Cortez; that was in January 2015. And it worked so well that “we’ve been on pilot ever since.” It was the first in the U.S., and is still one of only a handful in the country.

Led by the police department, the Chelsea version adopted many procedures from the Canadian program, and just about all of them have remained part of the program throughout the years. In the last four years, the hub has addressed almost 500 cases.

The group, which is composed of employees from roughly 30 social service groups and agencies, meets around a table every Thursday for 90 minutes. Cortez, the facilitator, will introduce a “situation” to the group: an encounter the police or another hub member had with a particular person who they think can benefit from the hub’s collaborative approach. In order to meet privacy requirements—after all, service providers can’t just freely share private citizens’ details—the case has to pass certain filters that are discussed at the meeting. Does the situation involve several service sectors? Is the person at an acutely elevated level of risk? When the answers are yes, the hub is allowed to openly discuss the person’s name and specific details of their case, and the pertinent agencies are identified.

Determining all of that takes about four minutes, and Cortez will then go on to the next situation. But later, the relevant groups will reconvene and hammer out a plan to work with the individual at risk.

There are several key elements to the Chelsea Hub that contribute to its success. Shortly before the hub launched, a mental health agency had hired two outreach workers they dubbed “navigators”—people with addiction experience who could connect with at-risk individuals. Their hiring was serendipitous, but they turned out to be invaluable to the hub’s work; the navigators have a much easier time building relationships with the target population than social services staff, according to Cortez and others.

And that’s key, says Cortez. “We’ve learned that if you don’t do relentless outreach, something bad could happen.” That is, some people in need of help require repeated engagement before they decide to change their behavior.

A second key element is the local hospital’s participation. The closest emergency room is CHA Everett Hospital, just over the border in another municipality, and initially, the hospital had little contact with the hub. That created a real break in the chain of communication; after all, the ER is a frequent destination for people with substance abuse problems or mental health issues.

Cortez remembers visiting the ER waiting room, back in the hub’s early days. “I’m standing there thinking, ‘I know everybody in here’—these were all people we’d been trying to help,’” he says. He finally reached out to the chief of the emergency department, Dr. Melisa Lai-Becker, and she responded eagerly.

“I said, ‘Oh my God, you’re going to be our savior,’” remembers Lai-Becker. The hospital had been looking to connect more deeply with other organizations in the region; the institution had its own social workers and case managers, but their contacts and institutional memory were limited.

Adding ER representatives to the weekly hub meetings has been incredibly useful. Today, hospital staff don’t just release indigent patients hoping they’ll be OK; they can be immediately connected to a web of supportive services. Substance abusers who need a diagnosis or medical clearance before they can enter residential treatment can quickly be seen; those with acute medical needs can be encouraged to stay in the hospital until their illnesses are treated.

And two new recovery coaches recently started working solely in the ER, where they can quickly connect patients with help. They’re aren’t formally part of the hub, but work closely with the group.

That’s critical. Before the hub, “we really weren’t all that sure if our patient was going to be OK [when released]. Now, there are a lot of other people who can catch the baton,” says Lai-Becker. “We’re able to provide such better quality of care to this highly vulnerable population. It’s such a relief.”

The hub has had a quantitative impact. Crime in Chelsea has dropped, and last year, the city finally slipped off the list of 100 most dangerous American cities.

Just as important are the qualitative outcomes. Hub members have become close friends and now often collaborate informally to help struggling residents who might not technically qualify as a “situation.” That cooperation might not add to the hub’s statistics, but it does benefit the city and its residents.

For example, eight months into recovery, the woman mentioned earlier wound up relapsing. Police found her on the street and normally would’ve taken her to jail. But because they knew she had been supported by the hub, they called Cortez. “We don’t want to arrest her,” they said. “Can you send a navigator?” Within two days, she was back in treatment.

The initiative is not foolproof, of course. But with time and experience, hub members have gotten increasingly good at figuring out how to help people. A local CDC, the Neighborhood Developers, keeps data on each situation and makes it available to all hub members, allowing them to identify patterns and locate deficiencies in the system.

And it’s cheap: the hub itself doesn’t cost anything. While case workers from various social service agencies commit a few extra hours to the weekly meeting, Cortez and several others say that the relationships built there make other aspects of their jobs easier. Plus, Cortez explains, “It energizes them, and their professional capacity increases.”

The navigators, though, are an integral part of the initiative and do cost money. The city of Chelsea funds the navigators who work on the streets; the cost is $125,000 for two, including incidentals. The coaches who work in the ER, meanwhile, are paid by grants from the Cambridge Health Alliance (CHA) Foundation, the philanthropic wing of the company that runs the Everett Hospital; their total is roughly $100,000. Rebecca Sweeney, senior director of care management at CHA, admits that the funding is uncertain; she’d like to see insurers eventually foot the bill. But until then, CHA plans to continue to fund the coaches. It’s worth it, she says.

“Our patients would cycle in and out of the [emergency department] and hospital without ever meaningfully engaging in treatment. The recovery coaches changed that,” Sweeney says. “Patients who want nothing to do with ‘white coats and clipboards’ will talk to the coaches, listen to them, engage with them, and often let them help navigate them into treatment.”

Cortez is similarly enthusiastic when he talks about the game-changer that the entire program has wound up being. “We used to be the place where people went to buy the best drugs; now people lie and say they’re from Chelsea so they can get help,” says Cortez. “You hear those awful situations people are in, and then the next week, there’s a very good chance you’ll hear an amazing outcome.”

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