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The Cincinnati Child Health-Law Partnership (Child HeLP) is a collaboration between Cincinnati Children’s Hospital Medical Center and the Legal Aid Society of Greater Cincinnati.
Attorneys and paralegals from Legal Aid work in the hospital’s Pediatric Primary Care Center (PPCC) five days a week. They provide information, advice and advocacy to resolve legal issues affecting the health and well-being of children and families. The problems they work on range from unsafe housing to income and food benefits or health benefits to which families are entitled.
The PPCC has nearly 35,000 visits to its clinic yearly and nearly 500 families each year are referred to Legal Aid for assistance. Referrals from the hospital’s three primary care clinics make up 10 percent of Legal Aid’s total workload.
When a child shows up in the emergency department with asthma symptoms so severe he has to be admitted to the hospital, doctors do what they are trained to do. They treat the acute symptoms, get him better, and send him home with medication.
But what if home is the problem?
And what if, over the course of a few months, 13 kids from the same location show up with the same symptoms? What do the doctors do then?
If you are part of the team that works in the Division of General and Community Pediatrics at Cincinnati Children’s, you do not just shrug and move on to the next case.
“The more we can get physicians helping families and thinking about fundamental causes of a child’s poor health, the more helpful the interventions will be,” says Robert Kahn, MD, MPH.
Kahn and his team are working to get physicians to go beyond traditional ways of treating children’s medical conditions. They are involved in a four-year, $1.8 million, NIH-funded study that looks at the role social and environmental factors play in a child’s health – in this case, asthma.
By identifying and understanding all of the contributing factors – including those that go beyond the usual purview of the medical team – they hope to enable the child to better manage his condition and avoid the need for future visits to the emergency room.
The asthma study began in August 2010. The team enrolled 600 children within the first 10 months – more than twice the expected enrollment.
One of the study’s investigators is Andrew Beck, MD, in his third year of a fellowship in General and Community Pediatrics. Beck says they chose to focus on asthma because of its prevalence in children in this region “and it has an environmental and social component.”
The study includes “geocoding” each child who participates from the address his family provides. The coding, Beck explains, gives researchers information such as income, education, poverty levels and housing characteristics of a neighborhood.
Geography has often been used as a data point in public health studies, Beck says, but is new to hospital-based research. “We’re trying to determine how to bring geography into the mix at the bedside,” he says, “and whether we can use data sources normally not used to pick up social risks.”
Picking up those social risks could trigger interventions that would help the child and his family beyond the hospital stay.
“If Legal Aid or the health department tells us that certain buildings are in terrible shape, we can look at which kids we have living in those buildings,” Beck explains. “Or if we identify kids who are living in squalor, we can go to Legal Aid or the health department and say, ‘What do you know about these buildings’? That kind of cross talk between us and government and non-profits within our community is a way to step up our interventions. Many of the services already exist, it is just a matter of figuring out what they are and how to use them effectively.”
It was just such a collaboration that identified a common issue with 13 children from the Primary Care Clinic. The Legal Aid team working on site at Cincinnati Children’s (see sidebar) found that all 13 children lived in housing owned by the same developer, who had neglected the apartments and allowed them to become squalid. Legal Aid helped the tenants form an association and got the property owner to repair the buildings.
It is a powerful example, says Kahn, of how doctors and community agencies can work together to solve a health problem at its source. But it begins by asking the right questions.
“It starts by making sure we identify housing and environmental issues as risk factors when children come in to the hospital, and doing that in a much more standardized way,” Kahn says. “We are now testing interventions to make sure that the family of every child admitted with asthma gets asked those questions.”
Asking “those questions” is not easy, says Melissa Klein, MD. It is her job to help develop interventions and to train residents to use them.
Klein, a general pediatrician who focuses on underserved populations, directs the primary care track of our residency program. She recalls a survey that found residents were picking up on a critical nutrition problem in infants only a fraction of the time.
The reason? They were not comfortable asking what she terms “the sensitive social questions.”
“It’s easy to ask a mother about baby poop. It’s really hard to ask her about depression, hunger or unsafe housing,” she says.
Klein is working on ways to make asking those questions as much a part of the medical evaluation as taking blood pressure. Beyond better training for residents, she is working to embed such questions into the electronic medical record to ensure they become standard screening during well-child checks.
Kahn says some may see these approaches as more of a burden on already stressed medical teams. But he argues that this is a form of preventive medicine that is not unlike other types of specialist referrals.
“It’s not the doctor’s job to do a home visit and help clean the house, but it is our job to know that toxic housing conditions are an issue before we just prescribe stronger medicines,” Kahn says. “We make referrals to allergy or pulmonary specialists, when what a family might really need is a cure for sick housing. We need to know who in the community can be most effective at getting that work done.”
Kahn and his team have created such a model within the hospital’s Primary Care Clinic, which sees some 35,000 patient visits each year. The clinic offers on-site legal assistance five days a week and has built solid partnerships with the city health department and the Freestore Foodbank to help the clinic provide formula to infants in needy families.
In places where more people face poorer health in increasingly difficult circumstances, it is an approach to healthcare that makes sense. “We can treat the symptoms or we can treat the symptoms while looking for upstream solutions,” Kahn says.
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