Based on an interview with Dr Bhavan for the AMA STEPS Forward™ podcast, and an interview with Natalie Boyle. Quotes and interview transcript edited and reformatted for clarity.
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Learn how collaboration between Parkland Health (Parkland) and Mommies in Need addresses a key social need in the community—free, accessible, drop-in childcare during medical appointments or treatment
“One of the leading causes of missed appointments or delaying time to care was not having a safe place to leave their child.”
—Kavita Bhavan, MD
Parkland serves some of the most vulnerable communities in Northern Texas. The majority of patients are uninsured or underinsured, and many live in communities impacted by multiple health disparities, such as lack of access to prenatal care, preventive care, healthy food, and stable housing. If those patients have young children, difficulty scheduling potentially costly and last-minute childcare compounds the challenges they already face getting to medical appointments or receiving life-saving treatment.
Observation and inquiry at Parkland's women's health clinics uncovered that it was common for little children to be present with their parent in the waiting room and then, by necessity, left with a stranger while the parent went into their appointment. COVID-19 further changed things. New COVID-19 restrictions meant that parents could no longer bring small children into clinical settings. This created even more barriers to obtaining care; for example, someone seeking prenatal care for their second child had no safe place for their older child to be during an appointment. A striking example of this was a sharp decline in visitors to the neonatal intensive care unit, with parents saying that the reason they couldn't visit was that they needed to bring older children with them, and COVID policies prevented them from doing so.
“On an airplane, we tell people: Place the oxygen mask on yourself first and then on the child. But here we have time-sensitive, crisis situations, seen with medical diagnoses such as cancer, where people are actually postponing chemotherapy or necessary surgery because they don't have a safe place to put their child. And it's really not a choice that's reasonable to ask people to make.”
—Kavita Bhavan, MD
Natalie Boyle, founder of Mommies in Need, a 501c3 nonprofit, witnessed this challenge firsthand when a good friend was undergoing cancer treatment. Her friend did not have the resources to afford a nanny or other childcare on her treatment or recovery days. Upon the recommendation of one of the nonprofit's board members, Ms Boyle approached Parkland and connected with Dr Bhavan. Together, they came to realize the depth of need for Parkland patients and set about establishing a partnership to solve this challenge.
Developing the Intervention
Mommies in Need, the nonprofit that Ms Boyle founded, helps women attend chemotherapy and other appointments by providing in-home childcare for parent-patients. Mommies in Need employs specially trained nannies, social workers, and a play therapist, offering up to 40 hours of childcare a week for up to 6 months. Over the course of her work with parent-patients, she encountered situations where the in-home model of Mommies in Need wasn't suitable because the home environment wasn't conducive to bringing in a nanny or because parent-patients were experiencing housing instability. She approached Parkland looking for a way to help parent-patients who were not a good fit for Mommies in Need.
In partnership with Parkland, the Mommies in Need childcare model was expanded with the establishment of Annie's Place: an on-campus drop-off childcare center to care for children of patients during their medical appointments.
Annie's Place opened in November 2020—right in the middle of the COVID-19 pandemic—and is named in honor of Ms Boyle's friend who was the impetus for founding Mommies in Need. All staff are employees of Mommies in Need, and Annie's Place has the capacity and capabilities to serve thousands of families. Special training and low staffing ratios acknowledge the unique social-emotional needs of children who may rarely or never be cared for by someone other than a parent or guardian. Nutritional meals and early childhood support are also available onsite. In fact, Annie's Place provides everything a child might need during the day, from diapers to wipes to a change of clothes.
Recognizing that social determinants of health domains often correlate, a social worker is available to inquire about other needs, such as food insecurity, and direct parents to appropriate resources for help. One somewhat surprising positive that has come out of having onsite social workers is uncovering previously undiagnosed speech or developmental delays. Social workers can refer children to specialists to confirm their diagnosis.
To facilitate referrals from Annie's Place without creating more EHR work, the team at Parkland used existing workflows that were familiar to nurses, care managers, and social workers to develop a novel dashboard. This new dashboard helped overcome logistical issues, yielding a seamless approach for placing referrals and communicating them between the hospital, clinic, and Annie's Place. In addition, Annie's Place team members can place flags on a patient's record to alert the clinic or hospital that the patient has a child under their care. Then, if there's an emergency and a parent-patient is unexpectedly admitted, Annie's Place can contact another caregiver. These unexpected emergencies revealed another benefit. It is often easier for Annie's Place to gather updates to sections in a patient's profile that patients may skip when filling out a pre-visit questionnaire or may not be able to access before an appointment, such as current address and emergency contacts.
Figure 1 depicts factors that contributed to the successful creation and launch of Annie's Place.
The solid collaborative work to establish Annie's Place has highlighted an unmet need and a solution. Families are not only accessing childcare for crises but also preventive health visits.
BY THE NUMBERS
25 to 30 children cared for each day
22 babies born while a sibling was at Annie's Place
2000 medical appointments for parent-patients since November 2020
Annie's Place team members shared several remarkable stories of the importance of having a safe place for children to play while a parent is at the hospital, including:
A woman who was seven months pregnant and had not been able to access prenatal care because of childcare issues finally saw her doctor
Women scheduling hysterectomies and surgery for tumors are able to make and keep appointments
Using the facility for respite care for a variety of circumstances
In response to finding that some children were learning of a mother's breast cancer diagnosis for the first time during pickup from the center, Annie's Place added a full-time play therapist to the team. Now, children can work with the therapist to help with the stress these situations can place on a family. The play therapist is available for ongoing 1:1 sessions, crisis interventions, and parent consults.
With the availability of childcare through Annie's Place, Parkland hopes to reduce disparities such as those in rates of breast cancer screening and diagnosis in communities of color. Currently, Parkland uses qualitative and quantitative mixed methods research to better understand experiences with Annie's Place and health care from the user's perspective and the barriers for those not accessing these services. Eventually, they hope to understand the impact that Annie's Place might have on clinical outcomes over time to encourage other health care systems to adopt a similar model to support their patients.
One Mom's Story: From Routine Visit to Emergency and a Child Protective Services Case
The appointment was supposed to be routine—in and out for a shot that takes 15 minutes. But the appointment turned into an emergency requiring a blood transfusion. This was a critical health visit, and the mom had no childcare. So, she left her young son in the car in the clinic parking lot. She told him not to talk to strangers and not open the door for anyone. When the mom alerted the care team that her son was in the car, a nurse went outside and had to convince the child to open the car doors. Because the nurse is a mandated reporter, she had to inform child protective services of the situation and a child endangerment case was opened.
After this incident, the mom was referred to Annie's Place so that she would have childcare for future appointments. The social worker at Annie's Place assisted the CPS social worker to close the mom's case. With Annie's Place support, the mom was also able to catch up on her much-needed medical appointments.
Annie's Place is the culmination of efforts to think beyond traditional social determinants of health (eg, food or housing insecurity) that impact access to care. Currently, Annie's Place is mainly funded through philanthropic support. Parkland provided the space on campus in an unused building along with a free lease, and Mommies in Need renovated it into an open, inviting, and welcoming facility. Parkland provides environmental services (cleaning) and security for Annie's Place. Mommies in Need handles all aspects of operations and programming for Annie's Place.
For Dr Bhavan and her team at the Center for Innovation and Value at Parkland, this was her first experience working as part of a health system–community organization partnership. It was important to align the mission and values for both groups to move forward. Mommies in Need brought expertise in childcare from the private sector, and there was a long-term vision for childcare. Having Parkland senior leadership on board also contributed to the successful establishment of Annie's Place because it meant that Annie's Place would be integrated into the network like a clinic without being a clinical setting.
Ms Boyle is currently exploring the expansion of Annie's Place to other hospital systems.
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