Joanne Cox, MD has worked at the Primary Care Center at Boston Children’s Hospital for 30 years and served as director for the last 15.
“Every day, we see homeless children and children who’ve experienced violence in their home or community,” she says. “I’ve seen babies grow up in these situations and witnessed the long-term, negative affects … how it hinders them from succeeding in school and then from succeeding as young adults.”
The biggest issue, says Cox, is poverty. When it comes to social determinants of health — defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age” — poverty has the largest impact on health inequities. Studies show that children born into poverty have of infant mortality, low birth rate and chronic illnesses such as asthma, type 2 diabetes and obesity.
“When parents are focused on food, shelter and the needs of daily life, they’re focused on that and not parenting,” says Cox. “In our primary care clinic, we’ve done a lot to address these issues.”
Pediatricians have long been aware of the impact poverty has on the health of their patients, but addressing issues that extend beyond medical care is not easy. However, there are certain things that primary care clinics can do to help patients and families with social determinants of health. Cox recently co-authored a paper for Pediatrics that outlines practices such as these.
Support child care and early education
“We put a lot of focus on early-childhood school and day care,” says Cox. The clinic runs a number of groups for parents, sort of like parenting clubs, that teach important skills, such as how to praise your child’s good behavior and approach behavioral problems.
The groups are run by social workers and target different age groups and cohorts. For example, one group is for parents of preschool-aged children and another is for parents of children diagnosed with ADHD.
To address the needs of newborns, the clinic has also initiated a group visit for mothers of babies under a month old. The session is conducted in the Hale Center for Families and draws three to seven families each time.
The Young Parents Program, which has been running since 1980, closely integrates social workers into the medical care model. “Most teen parents today have significant behavioral health problems,” says Cox. “Our program is focused on protecting the children and helping their mothers.”
Teen parents who are patients of the center are automatically enrolled in the program. “We do lots of mindfulness exercises,” says Cox, adding, “The girls really like yoga.”
Utilize non-clinical staff
The Boston Children’s Primary Care Center cares for 15,000 patients every year at a total of 45,000 clinic visits. To adequately address the various needs that indirectly affect patient health, the center has a team of non-medical staff.
“Social workers are a core part of what we do,” says Cox. “And access is a big part of the picture when you talk about social determinants of health.”
Resource specialists and “patient navigators” access resources and other services they may need, such as transportation, nutritious and affordable meals and child care.
“Patients like to be able to call their navigator,” says Cox. “They like that personal touch.”
Integrate behavioral health into primary care
The Primary Care Center is “beginning to get much more structured about behavioral health,” says Cox. Two years ago, it adopted an integrated care model, with social workers and psychologists on site.
A number of assessments and screenings are now part of the normal workup for all clinic visits. There are screenings for mental health issues, such as postpartum depression, and also screenings for things like food insecurity and violence in the home.
If a patient screens positive for an issue, the social worker and/ or psychologist on duty is called over right then and there. “It’s been extremely effective,” says Cox, “and we believe the model will be cost-saving in the long run.”
Know your community’s needs
A recurring, community-health-needs assessment conducted by the hospital indicated that asthma is a major problem in the lower-income communities of Boston.
So Boston Children’s launched a Community Asthma Initiative (CIA), which sends a nurse and an asthma educator to the homes of patients in these areas to assess potential environmental hazards (such as dust and allergens) and educate family members on the things that cause and exacerbate childhood asthma. The program began in 2005; by 2012, asthma-related visits to the Boston Children’s emergency room had decreased by 68 percent.
Connect with area services
“We give out a lot of camp scholarships to local camps such as the Boys and Girls Club, thanks to money donated to the clinic,” says Cox.
She adds that it’s important to know what social agencies are out there. “Healthy baby, healthy child is an organization within the Boston Public Health Commission that provides free home health visits to pregnant and parenting families in Boston with a child under the age of five. We also work with a medical legal partnership to help families fight evictions and other legal issues.”
Learn more about Primary Care at Boston Children’s Hospital