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COMMUNITY BENEFIT REPORT 2012 Cincinnati Childrenâ€™s Hospital Medical Center 3333 Burnet Avenue | Cincinnati, Ohio 45229-3026 www.cincinnatichildrens.org 4064 0513 001900
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Dear Friends, Cincinnati Children’s is deeply committed to providing outstanding services to all patients in our care. At the same time, we recognize that our responsibility to the Cincinnati community extends beyond the walls of the hospital. Our annual community benefit report shines a light on our community-oriented activities. One way we’re reaching beyond the hospital is by focusing on health, not just healthcare. In this report, you’ll read about programs designed to keep kids healthier by: •
Partnering with community agencies to improve housing for children whose asthma is worsened by environmental exposures Finding new ways to encourage children with sickle cell disease to follow treatment regimens that keep them out of the hospital Helping low-income pregnant women have healthier pregnancies and deliver healthy, full-term babies Giving doctors in our residency program opportunities to teach about health and serve as mentors to children in area schools Teaching young men in juvenile detention the skills to make more responsible health and life decisions.
Through these and other activities, Cincinnati Children’s provided $527 million in community benefit services in 2012. We will soon expand our role as the safety net provider for children and teens with medical, dental and mental health needs. In summer 2013, we will launch the Health Network by Cincinnati Children’s, which will provide for the overall health of children insured through Ohio’s Medicaid system. As Ohio grapples with the challenge of controlling healthcare costs and improving outcomes, we want to be part of the solution. Through our Health Network, we’ll build on the successful programs described in this report, intensify our efforts to promote health and wellness, and work to improve our own efficiency, teamwork and care coordination. It is our pleasure to provide this community benefit report. We also thank the many supporters and partners who work with us to improve child health and enhance the quality of life in our community.We’re advocating on behalf of children’s health with local, state and national policy makers.
MIchael Fisher President and CEO
what is community benefit?
safety net for children
Community benefit is defined as programs or activities that provide treatment, or promote health and healing, in response to identified community needs.
As our region’s pediatric safety net hospital, Cincinnati Children’s has a longstanding commitment to serve every child in our primary service area, regardless of ability to pay. To meet the needs of low-income families, we provide many essential services including primary care and dental care in addition to hospital and emergency care. Currently 43 percent of our patient encounters are covered by Medicaid. In fiscal 2012, there was a 15 percent gap between the cost of providing care to these children and the amount we were reimbursed.
Providing community benefit is part of our DNA. While Cincinnati Children’s has become a national and international leader in pediatrics, we are deeply rooted in the community that has been our home since 1883. We demonstrate our commitment to children and families in Hamilton County and Greater Cincinnati by investing significant resources in programs and services that meet these community benefit objectives: •
Improve access to healthcare
Enhance the health of the community
Advance medical or healthcare knowledge
Lessen the burden on government or other community efforts.
4 259l .i o n mil
In addition, Cincinnati Children’s is committed to providing much-needed mental health services, despite poor reimbursement from both commercial and public insurance. In 2011, Cincinnati Children’s launched a collaboration with the Lindner Center of HOPE to expand access to mental healthcare for families in our community.
C H A R I TA B L E PAT I E N T CA R E Free or discounted services for those unable to pay. The benefit amount includes the loss from providing charity care and the shortfall from Medicaid reimbursement, after accounting for support from the Hamilton County Health and Hospitalization Levy and the Hospital Care Assurance Program.
S U B S I D I Z E D H E A LT H S E R V I C E S
2 .8o n
5 199.o n mill
RESEARCH Laboratory science and applied research costs that are internally supported, including facilities, equipment and research not covered by grants and industry support.
2 .7o n
M E D I CA L E D U CAT I O N
Clinical services provided despite a financial loss to the organization. Mental health, dental and primary care services are among these hospital-subsidized services. We calculate financial loss after subtracting bad debt, charity care, Medicaid and losses from other assistance programs.
COMMUNITY OUTREACH Programs that provide services or support directly to the community or to nonprofit organizations with similar missions of service, including health education, injury prevention and wellness initiatives.
T OTA L
$ 527 million
Cost of providing education to prospective physicians, less federal support of our graduate medical education program.
D E R I P INS
G N U YO E L P O PE Each month, Cincinnati Children’s residents teach kids in area schools about health and life.
INSPIRING YOUNG PEOPLE THROUGH TEACHING AND MENTORING Ask any pediatric resident how much free time she has, and you are likely to get that look. Free time? Really? Between rounds, classes, meetings and clinical rotations, finding free time is tough. And using that extra time to volunteer in the community? Even tougher. Still, no one was surprised when residents at Cincinnati Children’s started asking for more volunteer opportunities. “Our residents chose pediatrics for a reason,” says Ndidi Unaka, MD, an associate program director in the Residency Program. “They have a heart to serve others. It’s why they went into this profession in the first place.”
Second-year resident Gregg Kottyan, MD, talks with eighth graders at Rockdale Academy.
Cincinnati Children’s has an advocacy rotation for all first year residents. But many residents wanted more, so Unaka took on the role of linking them with opportunities for greater involvement. One such opportunity is led by second year resident Gregg Kottyan, MD. The TEAM (Teach, Educate,
Advocate, Mentor) program enables residents to give monthly talks to students at Rockdale Academy and South Avondale Elementary schools. Once each month, residents talk with several classes at each school. “We work with the schools to come up with topics they are interested in,” Kottyan says. “Topics have ranged from healthy eating and physical activity to ‘good touch/bad touch’ and careers.” Kottyan, who is in the pediatric primary care track, says the talks are well received by teachers and students alike. “Some grades can be a tougher audience than others, but most are really attentive and ask great questions,” he says. He says residents find the program “very rewarding,” and good preparation for their chosen careers. “For pediatricians – especially those who go into primary care – most of your job is education. Getting used to talking with kids and parents really helps you prepare for that.” Unaka adds that residents’ volunteer activities, particularly with children and families in underserved communities, are valuable no matter what their specialty. “All of our residents will be doing some sort of advocacy in their career, no matter if they choose to be a general pediatrician or a specialist,” she says. “It’s something every pediatrician needs to be well-versed in.”
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teaching responsible fatherhood Tony Davis (far left) and Dr. Paula Braverman work with local corrections officers to teach juvenile offenders to make better decisions about their lives and their futures.
Every month at the Hamilton County Youth Center, small groups of teen boys at the juvenile detention facility gather to talk about a role in life that few of them are prepared to play: being a father. More than 1,700 babies a year are born to teen mothers in Hamilton County. Many of those babies were also fathered by a teenager — a father who likely plays no role as a parent. Despite recent declines in teen birth rates, teen pregnancy remains a major social issue that disrupts the lives of thousands of families every year and costs taxpayers billions in health care, foster care and other expenses. The Man2Man: Cincinnati program seeks to reduce the burden of teen pregnancy by focusing on the male half of the equation.
330,000: the number of babies in the US born in 2011 to girls between 15 and 19 years old. “Many teen pregnancy prevention programs are focused on the mothers, but there is an increasing emphasis on encouraging responsible fatherhood,” says Paula Braverman, MD, director of community programs in the Division of Adolescent Medicine at Cincinnati Children’s.
“Participants learn about contraception and preventing sexually transmitted diseases,” Braverman says. “But it’s much more about learning good communication, understanding relationships and thinking about who they want to be when they get older.” Cincinnati Children’s launched the program in 2009 in collaboration with the Hamilton County Juvenile Court. Its curriculum is based on a high school program that Braverman helped launch in Philadelphia in collaboration with the Family Planning Council. The biggest changes: the Cincinnati program reflects resources and laws specific to Hamilton County and Ohio and was adapted to fit into a juvenile justice setting. Man2Man: Cincinnati focuses on youth offenders because they are among the highest risk groups of adolescents for unplanned pregnancy and sexually transmitted diseases, Braverman says. The program is taught once a month in six straight daily sessions, mostly to boys between 14 and 16 years old. Juvenile corrections officers trained to serve as facilitators lead the two-hour sessions.
The program provides a non-judgmental forum for boys to discuss their thoughts and experiences and to learn from other men, says Tony Davis, a health education specialist at Cincinnati Children’s who trains the facilitators. Many of the boys grew up without a father at home, so the sessions often get into new territory for them. “We talk about the meaning of manhood and what it takes to support and protect a family, the financial costs and the time commitments. We talk about how important it is to be there for your child,” Davis says.
$11 BILLION: the estimated cost to US taxpayers for health care, foster care and other costs related to teen pregnancy. their intentions and increased confidence to engage in preventive behaviors,” she says. Davis says the program also makes differences in ways that may not show up in statistics. “Anytime you make an impact on one individual and change their perspective, it helps reduce the problems faced by the larger community,” Davis says.
1,700: the number of babies born annually to teen mothers in Hamilton County. The program is too new to measure its impact on teen pregnancy rates. But Braverman says before-and-after surveys show progress has occurred. “The participants show improvement in their knowledge about responsible behavior, changes in
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S D KI Dr. Lori Crosby conducts research focused on helping kids remember to take medications regularly.
MOTIVATING KIDS TO TAKE VITAL MEDICATIONS Shanoah Moore is a straight-A student. She plays in her school band, serves on student council, is a member of the National Honor Society and does gymnastics. But taking medication for her sickle cell disease proved a challenge for the 10-year-old fifth grader. Shanoah had been treated for sickle cell at Cincinnati Children’s since birth. But when her doctors recommended a new – and challenging – medication, Shanoah and her family needed some support. “They were very good at answering our questions,” says Sonya Moore, Shanoah’s mom. Doctors recommended Shanoah start taking hydroxyurea, a powerful chemotherapy agent that increases the production of fetal hemoglobin and reduces painful episodes and red blood cell sickling. Like every drug, it has side effects, a big reason why patients have trouble sticking with their regimen. Lori Crosby, PsyD, a psychologist in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati
Children’s, conducts research aimed at helping children with chronic conditions take their medicines. Because improvement is so closely linked to following medication schedules exactly, she says education is the first, most critical step. “If people do not understand the reason they’re supposed to take medications, it gets in the way. If they don’t believe it will help, it gets in the way,” Crosby says. To overcome these obstacles, Cincinnati Children’s caregivers are trained to talk frankly and often with families and patients about medications, using methods created by the Center for Adherence Promotion and Self-Management (see sidebar). “We are systematic in pre-planning and follow-up,” says Crosby. “When something is not working, we try to get to the next option as quickly as possible.” She adds that sometimes, a picture can be worth a thousand words. “If patients skip doses because they are skeptical about a drug, for instance,” Crosby says, “we sometimes show a chart of their lab values changing to help increase their motivation.” Ultimately, Shanoah’s family decided to let her take
With the help of methods she learned at Cincinnati Children’s, fifth grader Shanoah Moore never forgets to take her medication for sickle cell disease.
the new drug, in large part “because of the excellent care that Cincinnati Children’s has provided,” Sonya says. “We had built great relationships with the doctors and nurses and care providers who were part of Shanoah’s sickle-cell routine. They were very honest and transparent about it.” To help Shanoah adhere to her treatment, the Moores used the ROGER program (see sidebar) and MEMS caps on her medication bottles, with electronic chips that record every time she dispenses the medication. Taking medicine is now a regular dinnertime routine, and the family packs traveling doses for vacation. Now, Shanoah has no trouble sticking with her medication schedule, even on overnight visits to her grandparents. “She’s been taking it so long, she reminds them,” her mom says. “It’s her taking ownership.”
approaches cincinnati children’s uses to encourage adherence: ACCEPT
(Advancing Communication & Care by Engaging Patients)
(Remembering appointments and being On time; Getting medication and taking it Everyday equals Responsibility),
This tool uses Motivational Interviewing techniques in outpatient clinics. Providers are
A web-based self-assessment
trained in the technique and visits
tool that helps families pinpoint
to the sickle-cell clinic include
obstacles to adherence and
a meeting to discuss barriers to
find strategies to improve their
adherence and come up with
Events like Sickle Cell Disease Research and Education Day allow families to share solutions and hear about research findings. Our specialists work with teachers and administrators if in-school help is needed to support treatment.
L L FU M R E T
S E I B A B Dr. Elizabeth Kelly started a program to ensure that disadvantaged women receive early and ongoing prenatal care.
COMBINING HEART AND SCIENCE TO CURB PREMATURITY Too many babies in our state are born too early. Too many die before their first birthday. Each year in Ohio, nearly 18,000 infants are born at least three weeks before their due date. Well more than 1,000 infants die within their first year. The reasons are not well understood. But one innovative program has joined clinicians and researchers in an effort to stem the tide. Quality improvement (QI) researchers from the Anderson Center for Health Systems Excellence at Cincinnati Children’s have joined with clinicians at the University of Cincinnati (UC) and the Cincinnati Health Department to help low-income, uninsured women - the women most at risk of giving birth to preterm infants. It started with a program begun by Elizabeth Kelly, MD,
an obstetrician-gynecologist with UC’s Department of Obstetrics and Gynecology. Women could come to the Health Department’s Elm Street or Price Hill Health Centers and have a pregnancy test, receive their first “dose” of prenatal care and be connected with needed resources, all in one day. Kelly, who has spent her career caring for disadvantaged women, wanted to make regular prenatal care easier for patients who struggle just to get by, much less schedule and keep prenatal appointments. “Until a woman is free of things like being a victim of domestic violence, and has heat in her home, and food, and a ride to her appointments, it’s pretty hard for her to adhere to her health care,” she says. Kelly worked with QI researchers at Cincinnati Children’s to put four evidence-based interventions in place at the health centers: •
Same-day access to care
Help with social and economic concerns
Help to stop smoking or using other harmful substances
Ensuring a safe sleeping place for their newborns
Community health worker Lauren Bostick helps make sure that basic health and life needs are met so that women can deliver healthy, full-term babies.
“Until a woman is free of things like being a victim of domestic violence, and has heat in her home, and food, and a ride to her appointments, it’s pretty hard for her to adhere to her health care.”
Every woman who receives prenatal care at the Elm Street and Price Hill Health Centers is offered these interventions. QI researchers will track outcomes – which they hope will be healthy, full-term babies. Kelly is already seeing positive results. “Our patients love it,” she says. “They are genuinely concerned about their health and the health of their babies. This program allows more of their basic needs to be met so they can focus on staying healthier.”
Making sure “evidence-based” steps are taken Helping ensure that “evidence-based” health measures are followed is one of the many tasks of the community health worker.
Cincinnati Health Department. Her job is to make sure her pregnant clients remain healthy throughout their pregnancies. “Our primary responsibility is to establish a relationship with the women we care for,” says Bostick. “It’s why we do what we do.” What she does ranges from helping a homeless pregnant woman find housing to providing food and other essentials to a mother struggling to feed her family. Bostick makes sure mothers get to their medical appointments and their children get to the pediatrician. It can take many visits to establish trust and to keep a woman on course. But Bostick takes pride in the fact that many of the women she cares for are able to improve their life circumstances. Nearly all deliver healthy babies. And many keep in touch after their babies are born. “We may not always see immediate results, but I know that I sowed a seed in an individual’s life. And eventually things will change for the better,” she says. “What keeps us going is that every pregnant mother, and every child, matters.”
Lauren Bostick is a community health worker with the
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healing children by making homes healthier
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Gasping for air. Tightness and pain in the chest. Anxiety and panic. This is what an acute asthma episode can feel like. Roughly 150,000 such episodes each year lead to inpatient admissions for children nationwide, including more than 1,200 a year in our region.
Frustrated at treating children with severe asthma caused by poor housing conditions, Drs. Rob Kahn (left) and Andrew Beck work with the Cincinnati Legal Aid Society to get buildings repaired.
But something different happens when children with asthma come to Cincinnati Children’s. Beyond treating the asthma attack, physicians here dig deeper to find potential causes. Doctors know that thousands of Hamilton County children live in old, poorly maintained apartments. Science has shown that factors related to poor housing can make asthma worse. So when children with asthma need to be admitted to the hospital, physicians at Cincinnati Children’s ask some extra questions to assess environmental risks. Does their building have water damage? Is there mold on the walls? And when doctors hear about potential asthma risks, they take action.
Targeting buildings that make people sick In partnership with the Cincinnati Health Department, Cincinnati Children’s launched the Collaboration to Lessen Environmental Asthma Risks (CLEAR) in 2011 to help find and fix housing problems that contribute to triggering asthma attacks.
“Not so long ago, a question about housing was something a doctor would never ask. Now we make it standard practice.”
When families raise concerns, physicians alert health department sanitarians who have the authority to inspect properties and order repairs. So far, dozens of families have reported housing concerns. More than 50 properties have been inspected and more than 30 buildings have been repaired through the CLEAR program. “It’s not about what’s your job, what’s my job. It’s about the child and the child’s health,” says Andrew Beck, MD, MPH, assistant professor, General and Community Pediatrics and Hospital Medicine. “The depth of the partnership here is unique. This level of intervention is rarely available from the inpatient wards in other cities.”
child help program approaching 5th anniversary Cincinnati Children’s also partners with the Legal Aid Society of Cincinnati to help families address health and housing issues that extend beyond the hospital walls. When children come into the medical center’s three pediatric primary care clinics, pediatricians who learn about families facing problems can refer them directly to Legal Aid for further assistance. In fact, a Legal Aid paralegal or attorney works inside Cincinnati Children’s largest clinic five days a week.
Since its inception in 2008, the Child HeLP program has received more than 2,450 referrals seeking assistance with enrolling in Medicaid, securing food stamps, obtaining special school services and more. More than 700 new referrals occur each year. Some of the program’s biggest successes have involved addressing unhealthy housing. In 2009, a single referral to the Child HeLP program ultimately led to improvements made at 19 apartment buildings owned by a single absentee landlord.
“In the end, 677 apartment units were helped,” says Rob Kahn, MD, MPH, associate director of General and Community Pediatrics. “Not so long ago, asking a question about housing was something a doctor would never ask. Now we make it standard practice. We know bad housing is bad for asthma. So if we can partner with great community agencies to improve housing we know we can make a difference.”