Cincinnati Children's Hospital Medical Center
To gain a better understanding of cross-sectoral approaches to addressing the social determinants of health, AAHC is interviewing individuals from organizations that utilize non-healthcare approaches to improve health. Here, we look at organizations involved in medical-legal partnerships.
An interview with Melissa D. Klein and Andrew F. Beck
Melissa D. Klein, MD, MEd
Director, Residency Primary Care and Community Pediatrics, Associate Program Director, Education Section, Division of General and Community Pediatrics, Director, General Pediatrics Master Educator Fellowship, Attending Physician, Division of Hospital Medicine, Associate Professor, UC Department of Pediatrics, Cincinnati Children's Hospital
Andrew F. Beck, MD, MPH
Attending Physician, Division of Hospital Medicine, Assistant Professor, UC Department of Pediatrics, Cincinnati Children's Hospital
Describe what you do for work and the vision/mission of your organization.
Cincinnati Children’s Hospital Medical Center’s vision statement is “to be the leader in improving child health.” The Division of General and Community Pediatrics is at the forefront of helping achieve this. Our vision statement to provide “exceptional health for every child, together” more specifically focuses on children living in underserved settings. We believe that achieving these outcomes is only possible by working collaboratively with community partners, such as the Legal Aid Society of Greater Cincinnati and food banks.
Tell us about the socio-demographic and socioeconomic factors and conditions in the community, population, or constituency you or your organization serves.
The primary care clinics within the Division of General and Community Pediatrics at Cincinnati Children’s Hospital Medical Center serve as the medical home for 30,000 vulnerable children in Greater Cincinnati, 90 percent of whom are on Medicaid. The three clinics – Pediatric Primary Care Center (PPC) at the Burnet Campus, Hopple Street Health Center and Fairfield Primary Care Center – see more than 60,000 visits a year for well child care and ill visits. The families of children seen in our clinics often struggle to meet basic needs – as well as their educational, employment and, parenting goals – because they lack adequate resources and strong support systems. Family surveys in PPC reveal that nearly 25 percent of our patient families report either running out of food or eating less due to lack of resources, and one in three families worry their food will run out before they are financially able to buy more. Twenty percent reduce or skip meals due to lack of resources; of those, 30 percent do this almost every month. More than 25 percent of all caregivers lack a high school diploma. The vast majority of those are interested in programs that could help them receive one. Sixty-two percent of caregivers are unemployed, with the majority looking for work.
What is the link between the social determinants of health and your work?
According to 2010 U.S. Census Bureau estimates, one in five children in the 15-county region of Greater Cincinnati and Northern Kentucky lives in poverty. Cincinnati’s childhood poverty rate is estimated at 48 percent, third among major US cities. Poverty associated conditions, including food insecurity and housing instability, are linked to higher rates of behavioral, developmental, and learning problems in children. Additionally, substandard housing and homelessness have been linked to higher rates of illness, infections, asthma, and increased healthcare costs for children. We have documented over 50-fold differences in asthma admission rates across Hamilton County neighborhoods. In urban primary care pediatric settings, these social concerns are common and interrelated, with multiple hardships compounding the negative impact on health.
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Can you provide one or two examples of programs or activities that you are currently working on that is/are aimed at addressing an aspect of the social determinants of health?
We have had tremendous success in building effective partnerships with community agencies. The Cincinnati Child Health-Law Partnership (Child HeLP) is an innovative medical-legal partnership launched in 2008 between Cincinnati Children’s and the Legal Aid Society of Greater Cincinnati to help families resolve legal and social issues that undermine child health. The Legal Aid Society operates an on-site Child HeLP office in the PPC staffed by a Legal Aid attorney or paralegal and also accepts referrals from the Hopple Street and Fairfield clinics. Child HeLP now results in over 800 referrals per year with near perfect “handoffs” between healthcare and legal care. From January 2009 – December 2014, providers referred 4,071 patient families and Legal Aid recovered over $280,000 in public benefits for families, impacting 8,131 children and 4,151 adults in referred households. In addition, Child HeLP staff trained more than 325 pediatric residents in the social determinants of health.
Building on Child HeLP’s success, we developed Keeping Infants Nourished and Developing (KIND). KIND is a partnership between Cincinnati Children’s and the Freestore Foodbank, the region’s largest food bank, to minimize food insecurity among infants who are cared for in the clinics. With support from Procter & Gamble, the Freestore donates formula and diapers for distribution to needy clinic families. Since KIND’s implementation in March 2011, we have distributed over 4,000 cans of formula. KIND is now in 12 regional sites, including five Cincinnati Children’s clinics, four federally qualified health centers, two nonprofit health centers, and one hospital-based pediatric practice.
What are you goals for the program(s)? How do you measure and evaluate these goals?
Our overall goal for these and other community partnerships is to use the pediatric setting to help disadvantaged families ensure the best start possible for their children and connect them to resources that will help them on the path out of poverty. Through Child HeLP and KIND, our clinics seek to address emergency social and legal needs of families, including help with poor housing conditions, domestic violence, school issues, and hunger. We are currently developing new partnerships that seek to intervene upstream, before families are in crisis, to broaden our impact, and help prevent urgent needs. We aim to link parents with educational, employment, and parenting resources to help stabilize their children’s home and family life and guide them on a path to self-sufficiency.
Cincinnati Children’s maintains a culture of rigorous measurement, evaluation, and improvement in order to continually better serve families. We collect and use medical, legal and social outcome data to assess the success of each step in the program. We measure how often providers are screening and referring patients, what percent of families reach intake with community organizations, and the outcomes of referred cases when possible to determine. This system of measuring and tracking outcomes helps advance opportunities to share best practices of partnership creation, physician training, and program evaluation with peers across the country and across national networks – at meetings and in publications – leveraging our ability to impact thousands of low-income families nationwide.
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How do you financially sustain these programs?
Funding for Child HeLP comes from private individuals, foundation grants, and the National Center for Medical-Legal Partnership. In addition, the hospital contributes in-kind and financial support to the Legal Aid Society for administrative and operational activities. Funding for Keeping Infants Nourished and Developing comes from a grant from Procter & Gamble’s Live, Learn & Thrive initiative. Support for new partnerships comes from individuals, foundation grants, and hospital divisional funding.
Are there additional resources or partners needed to accomplish these goals? What are they?
Child HeLP and KIND have proven to be very successful interventions for families struggling with urgent needs. Our next step is to tap into the hope that parents have for their children to grow up safe and healthy, and for themselves to reach their own educational, employment, and parenting aspirations. This means connecting families to organizations that provide quality early child care and Head Start programs, job training and advancement, and General Educational Development (GED) preparation and testing. Key to the success of these new partnerships will be tailored opportunities for families to connect to these resources, both when they visit our clinics and when they are at home.
What opportunities do you see for connecting your work with the work of academic health centers?
Academic health centers are increasingly interested and engaged in population health initiatives. Such initiatives are likely to be most successful if they focus on medical and public health interventions while also paying close attention to the social determinants. It is within this realm that we see great opportunity for multidisciplinary, cross-institutional collaborations.
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