Health

An elite team of volunteers to fix health care: Q&A with Rebecca Onie

Posted by: Ben Lillie

At TEDMED 2012, Rebecca Onie stunned the audience with her blockbuster talk on a new vision for health care. She is the founder of Health Leads, an organization that brings an elite, competitive team of college volunteers into hospitals and clinics — a team that connects patients to services that help provide food, housing, insurance and other services that, for most conditions, are far more important to overall health than medications and procedures.

TED’s Ben Lillie caught up with her after the talk to learn more about the nature of Health Leads, and her optimism for the future. Watch her talk, featured today on TED.com, and read the interview below.

I love the sports metaphor — the idea that we can ask a tremendous amount of college students and make an elite volunteer squad. Taking on health care is an enormous task, but do you think it can expand even beyond that?

Absolutely. We would never assert that college students are the universal solution around addressing these basic resource needs. It’s more of a model that, if we recruit folks who are really committed to the work regardless of their background, give them excellent supervision and training, and have the right technology backbone, then those three things can be quite effective at addressing their basic resource needs. But our goal is to be able to use this non-clinical lay workforce to create more leverage for the existing clinical workforce. Especially as more and more patients enter the health care system. As there are expansions in coverage, the imperative to get the most of your workforce only increases.

What’s the training like? How intense and selective is it?

We run a competitive application process each year several times. And in some cycles we accept as few as 10 percent of the students who apply. They go through a 13- to 18-hour training that’s on everything from cultural competency to the resource landscape in their communities to, frankly, how do you talk to patients about difficult and sensitive issues. Then they make a minimum of a seven-hour-a-week commitment for an academic year – about three to four hours a week in the clinic, three to four hours a week doing follow-up with their patients, and then a required hour a week of what we call reflection sessions, which are essentially additional training, context setting.

If you’re going to work with college students in particular, part of what is essential is that they are intentionally exposed to the broader context of the relationship between health and poverty, what are the challenges and assets in the communities where they’re working. So often college campuses are the classic bubble. And students have real appetite to go beyond it, but we certainly feel an enormous sense of responsibility to make sure that, if that is going to happen, that they are really well-supported in doing so.

What kind of majors do your students tend to come from?

About 65 percent of the students are premed or otherwise intend to go into health care. But we recruit a diverse pool of students, partly because what we want to model is what an interdisciplinary team looks like in health care.

Do you have a favorite story of a volunteer student to whom something happened?

Sure. A mom brings her child in finally to see his pediatrician. He’s been in the E.R. with asthma. He’s come in three times in the past month or so with asthma-related visits. As the pediatrician digs further, it is revealed that they’re living with a dozen other people in this dilapidated brownstone in Baltimore, which is just terrible housing because there’s asbestos and lead paint. It’s also the middle of the winter and the heat got turned off, and cold air is an asthma trigger. It becomes so evident in that conversation that refilling the child’s controller medication, asthma controller medication, if done alone would be like a tree falling in the forest. This is at a clinic at Johns Hopkins Medical Center, so the family gets these dual prescriptions, both the controller medication, which of course is critical, but also for Health Leads.

Then one of our volunteers works with the family — connecting them with food because they’re running out of food at the end of the month, getting heat turned back on, actually getting them insurance so those visits to the doctor don’t cost the family as much, but actually, probably most importantly, getting mom connected to a job training program. Over time she’s able to secure them safe housing.

What do you feel like the volunteers take away from it? And are they going on to found other stuff?

I guess I would say two things. There’s the part that relates to their professional trajectories, and I think increasingly medical schools are looking at Health Leads on a resume as evidence of a real commitment to under-served patient populations and to primary care, and also just folks who are willing to commit to quite a rigorous experience.

I would say, at least as important, if not more important, is this combination of both a real sense of efficacy with respect to these issues – a sense of “I know I can do something” with respect to a challenge that’s often experienced as intractable — but pairing that efficacy with a real depth of understanding of how challenging the issues really are. Indeed, when folks have looked at why med students, for example, don’t go on to pursue primary care careers, it’s often because they, early on, discern that the social issues are such a huge part of what it means to be a primary care doctor, but don’t feel well equipped to deal with them, whereas our volunteers do.

And so a lot of the students leave, I think appropriately, frustrated with the existing systems in this country. And part of our aspiration is that they’ll walk away with both that sense of efficacy and an appetite to do real advocacy work. Those things paired together is what actually sets them on a more transformative trajectory. The goal is for them to be both inspired and pissed.

So what has your first class, from 1996, gone on to do?

Of that very first class of 10 volunteers, it’s really interesting. One of them has gone on to do health policy work on the Hill. One of them is now an attending physician at Children’s Hospital in Boston, with a research focus on asthma and housing. One of them is now also an attending physician at Brigham and Women’s at the neonatal unit with a focus on breastfeeding, especially in non-white patient populations. So it’s the set of things you would expect in some ways.

What happens if a volunteer’s working with a family and something goes horribly wrong? Is there a support system for them when that happens?

The volunteers are supervised on a day-to-day basis by our full-time staff who are physically located in the clinics with the volunteers. And the staff both play the role of integrating the model into the clinic and building relationships with the rest of the staff, but also providing direct support and supervision. Those program managers have case management or social work experience, and  they’re there to do exactly as you say, to help the students identify when the cases are of a complexity that’s beyond their training. And a not-insignificant number of those are, but we always say that we train the volunteers as intensively in what they don’t do as what they do do.

What’s a case that’s too complex?

It could be anything from domestic violence to maternal depression. These are families that are living in extremely complicated living situations often, and I think this is where working in tandem with the social work is really powerful. The social worker is probably is the best position to deal with maternal depression issues. And at the same time, those issues will never really be alleviated unless Mom gets out of a shelter. We help the social worker to delegate that resource need to the volunteer, and continue to work with Mom on the therapeutic need.

Do you have a volunteer who came to you in some really unexpected way? 

I had this really powerful conversation with one of our volunteers who had emigrated in 2006 from Belarus and came to the United States speaking literally not a word of English, and took ESL classes for a year and then did TOEFL and then applied to college and is now a premed student. She spoke so powerfully about how much her own family could have benefitted from a Health Leads desk. And her imperative to deliver excellence in working with her clients is so obviously motivated by a deeply personal understanding of what it means to come to a new country and be completely overwhelmed, and to feel in such need of assistance in navigating the systems and the landscape. I think that, frankly, whether our clients have actually immigrated to the United States or are just in marginalized communities within the United States, that that experience is pervasive.

Do you have anyone who was part of your system who then went on to college and became a volunteer?

Oh, that’s interesting. Not that I know of. Oftentimes our clients – not always, certainly – but oftentimes our clients are themselves young mothers. And so we’ll have volunteers who are working with clients who are their same age, with parallel life experiences. The volunteers, needless to say, learn an enormous amount from working with these clients, from the clients – and ideally vice versa.

What was the one thing you really wish you could have gotten in to your talk that didn’t make it in?

I guess what I would say is that I think this is a moment of enormous optimism around how financial incentives are evolving in ways that, from my perspective, are non-partisan. They have to do with a growing understanding that our health care costs are out of control and that, while government can influence it, there are other forces, like market forces, that are equally as powerful. I think there’s a real awakening around how we could fundamentally align those incentives with that co-aspiration for health care that I was referring to in my talk. And I think there’s a real need to embrace those incentives — it’s there for the taking in many ways.

It’s critical that we have an authentic sense of efficacy with respect to the design of our system: that it’s not just something that happens to us, that there are a set of choices that are being made and an opportunity to influence those choices. And I think that, frankly, in ways that haven’t been true historically, there is now an opportunity to influence some of those financial decisions. So that should be a source of hope.