Cincinnati Children’s Devotes Expertise and Resources to a Shared Community Mission
by Tim Bonfield
“Instead of focusing narrowly on traditional health measures, the challenge is how do we reduce the barriers to family success?” – Robert Kahn, MD, MPH
(From left) Drs. Uma Kotagal, Robert Kahn and William Brinkman have spearheaded development of the All Children Thrive Learning Network, which brings together government and community agencies, neighborhood leaders, and families to co-produce interventions to improve complex health concerns.
A new language is taking root among dozens of agencies and organizations dedicated to improving child health in Cincinnati.
The vocabulary includes terms such as community activation, family-centered design, co-production, quality improvement and social determinants of health. Now nurses, teachers, agency leaders, parents and neighbors are joining with physicians, scientists and other community health experts to talk about SMART aims, run charts, concurrent neighborhood controls, and more.
This is the language of the All Children Thrive Learning Network, a collaboration launched by Cincinnati Children’s and more than 30 other organizations to apply the science of quality improvement to some of the toughest, most complex problems affecting community health.
“It’s a way of working differently that we believe will lead to different results,” says William Brinkman, MD, MEd, MSc, Director of Research, Division of General and Community Pediatrics. “It’s a way of working together, as opposed to working in silos, to move the same dial with everyone using a shared system of measurement. It’s a way of providing evidence for people to use in decision making, a method that can allow people to stop holding onto ideas that haven’t worked.”
Going beyond treating illness
The city of Cincinnati is home to about 66,000 children, more than 40 percent of whom live in poverty—the third highest rate in the nation.
Research led by Cincinnati Children’s shows that children in the five least healthy of the county’s 80-plus neighborhoods have a 20-fold higher hospital admission rate. As they grow, many of these children are not well prepared to enter kindergarten. Many are not reading proficiently at third grade. Meanwhile, mothers in the five least healthy neighborhoods are three times more likely to have a preterm birth.
All Children Thrive represents an organized effort to reduce the massive health burdens caused by childhood poverty by involving the families these organizations are trying to help—not just as participants, but as leaders.
As a result, instead of a traditional focus on treating illness, the mission is more about helping children thrive. The network’s goals:
• Ensure all children reach their first birthday
• Ensure that all 5-year-olds have a “healthy mind and body”
• Reduce disparities in hospital admissions across neighborhoods
• Ensure that all children are reading proficiently by the end of third grade
All Children Thrive, launched in 2015, is hosted by Cincinnati Children’s and coordinated with leaders from multiple sectors. The network includes families, health care providers, educators, community service providers, and others. Members meet weekly to collaborate on systemic solutions carried out through numerous neighborhood-focused projects.
So far, more than 3,800 people have participated in collaborative events, training sessions and quality improvement “boot camps.” More than 45 “parent partners” have become active in two of Cincinnati’s most impoverished neighborhoods—Price Hill and Avondale.
More than 30 agency leaders have received quality improvement training through a program called Impact U in collaboration with the Strive Partnership. The United Way and the Greater Cincinnati Urban League are deeply involved.
Organizers of All Children Thrive established the Impact U program to train agency leaders and volunteers on quality improvement methods. So far, more than 3,800 people have participated in collaborative events, training sessions and quality improvement “boot camps.”
Meanwhile, Cincinnati Public Schools has connected many of its elementary teachers to a reading-focused quality improvement program that has spread to a dozen schools in just two years.
The heavy emphasis on educational goals is a crucial element of the All Children Thrive approach. Experts at Cincinnati Children’s and other centers have documented many of the brain development benefits that flow from early childhood reading. Social scientists have long known that when children fall behind in reading, they often fall behind on many other subjects, which can lead to lower high school graduation rates, increased poverty, and higher risks for a wide range of poor health outcomes.
The value of the learning network approach followed by All Children Thrive flows from assembling interested, committed people to work together towards improving measurable outcomes, says Uma Kotagal, MBBS, MSc, Executive Leader, Population and Community Health at Cincinnati Children’s.
“Solving a problem like poverty is too big. Solving a problem like literacy is too big,” Kotagal says. “What the network does is serve as a convener, a catalyst. For big problems, the network brings people together across multiple sectors to test different things and scale what works.
“All of our partners are deeply caring, very committed community leaders. We do not tell these people what they should do. We provide a structure they can use to bring quality improvement methods to their work. Providing these methods and co-producing with people in the community makes it possible to build energy and optimism.”
An evolution in improvement science
Cincinnati Children’s recent involvement in community health issues reflects a years-long commitment to quality improvement science.
The roots of All Children Thrive reach back as far as 2002, when Cincinnati Children’s received a $1.9 million “Pursuing Perfection” grant from the Robert Wood Johnson Foundation.
That quality improvement effort started with an internal focus to transform cystic fibrosis care, then expanded to other hospital processes. This process led to the formation of the James M. Anderson Center for Health Systems Excellence, launched in 2010 under Kotagal’s leadership, and now directed by Peter Margolis, MD, PhD, and Steve Muething, MD.
The Anderson Center develops and shares a wide range of evidence-based best practices for healthcare providers on topics ranging from hospital safety and capacity management to managing chronic disease. It has supported and facilitated more than a dozen learning networks involving hundreds of medical centers and physician practices, enabling Cincinnati Children’s to collaborate across the country to get results at scale.
One of the most significant of those has been ImproveCareNow, a group co-founded by Margolis to focus on inflammatory bowel diseases (IBD). The network brings patients, families and experts together to accelerate the adoption of best practices. Since its origins in 2007, the network has grown from six participating centers to more than 100 worldwide and has transformed care and outcomes for a generation of children with IBD.
This network approach has been extended to the All Children Thrive network in an effort to apply many of the concepts behind ImproveCareNow to a new level of complexity and challenge.
Devoting resources to the effort
Helping the children of Cincinnati become the healthiest in the nation through strong community partnerships is one of the pillars built into the medical center’s 2020 strategic plan.
In addition to supporting the work of All Children Thrive, Cincinnati Children’s is investing $11 million over five years in community redevelopment in Avondale. The work ranges from working with partners to provide interest-free, forgivable loans for housing rehab projects to investing $1.5 million in grants to smaller nonprofits to improve child health and expand workforce development.
Now, the medical center is expanding some of the successful projects that started in Avondale to another neighborhood: Price Hill. (For more about the work happening there, see page 24.)
“Instead of focusing narrowly on traditional health measures, the challenge,” says Robert Kahn, MD, MPH, Associate Chair for Community Health at Cincinnati Children’s, “is how do we reduce the barriers to family success? How do we get all the elements of a complex system—the job training agencies, the child welfare system, the health clinic, the schools, the housing groups—working hand in glove for a family? So we’re working with agencies to ask them, ‘How do we surface the systemic problems and change the rules?’ ”
Experts at Cincinnati Children’s already have devoted extensive research resources, including geospatial mapping techniques and other approaches, to expose the neighborhood-by-neighborhood disparities hiding within aggregated city, county, and statewide health data sets.
“It’s one thing to look at asthma morbidity for the county,” Kahn says. “It’s quite another to say here’s the asthma admission rate this month, by neighborhood, and then add housing, pollution and pharmacy use data to track risk factors. This is a set of data that few others in the country could have put together—and it helped paint a pretty clear picture of where we could and should be doing more.”
Results beginning to surface
What does thriving mean? In addition to disease-focused goals, the initiative has assembled a bundle of health measures that track immunization, obesity, dental, vision, speech, hearing, literacy and behavioral factors. Combined, the network seeks to achieve several specific goals by 2020, including:
• Raising the percentage of 5-year-olds meeting all the bundled targets from 13.4% to 40%
• Reducing infant mortality in Hamilton County to 6.0 per 1,000 births
• Increasing the percentage of Cincinnati Public Schools children achieving third-grade reading proficiency from 46.5 percent to 90 percent
Early progress has been documented for all of these and many other goals.
For example, in early 2006, the countywide infant mortality rate was as high as 13.24 per 1,000 births. By late 2016, after the launch of Cradle Cincinnati and other efforts, the rate had declined to 9.10. Within that countywide figure, the Start Strong pilot project in Avondale resulted in a dramatic decline in extreme preterm births. Now network leaders are working to expand the program to other parts of the city, and beyond. (For more details about the community’s infant mortality efforts, see page 16.)
“Avondale is a prototype for success in preterm birth,” Kotagal says. “Now, we know the components that went into how to do that, which in turn inspires the rest of the learning network to do the work that’s needed to scale up.”
Meanwhile, some of the literacy work happening in Cincinnati is attracting national attention. Kotagal and other partners are working with the Carnegie Foundation for the Advancement of Learning to share the lessons learned in Cincinnati. Planning meetings are set for later this spring to launch a meta-literacy network that could include school districts in other states, including Maryland, Tennessee, California and Colorado.
“It may be that other people have already addressed some of the problems we’ve been talking about. It may be that we can offer insights,” Kotagal says. “That’s the core idea behind learning networks: to see them grow, share and improve outcomes as quickly as possible.”