In this episode of the AMA STEPS Forward® podcast, Marie Brown, MD, AMA director of practice redesign, talks with Kavita Bhavan, MD, chief innovation officer at Parkland Health and Hospital System in Dallas, Texas, about how targeted health equity work helped build community trust and led to the establishment of Annie’s Place, a free childcare center for children of patients. Learn more about Annie’s Place.
- Kavita Bhavan, MD, chief innovation officer, Parkland Health
- Marie Brown, MD, director of practice redesign, American Medical Association
Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Brown: Hello listeners and thanks for joining us today. My name is Dr. Marie Brown. I am the American Medical Association director of practice redesign and have practiced internal medicine for over 30 years here in Chicago. I'm speaking today with Dr. Kavita Bhavan, chief innovation officer at Parkland Health and Hospital System in Dallas, Texas. She's also an associate professor of infectious disease at UT Southwestern. Dr. Bhavan, welcome.
Dr. Bhavan: Thank you. It's a pleasure to be here.
Dr. Brown: Why don't you tell the listeners a bit about yourself and your background.
Dr. Bhavan: Absolutely. As you mentioned, I am an infectious diseases physician by training. Proud to be an internal medicine physician for the last 20 some years. I moved to Dallas in 2009 and from 2009 to present day I've really been focusing my work on health disparities and thinking about health equity through the lens of practicing and the safety net setting. As you mentioned, I'm the chief innovation officer at Parkland Health and Hospital System, along with my academic appointment at UT Southwestern medical center. And in that capacity, the focus has really been to think about identifying health disparities and imagining or re-imagining how care can be delivered to improve health equity.
Dr. Brown: Fantastic and we so appreciate you taking the time to talk with us today. So, your work with equity, which we're going to focus on in the next 20 minutes or so, seems to focus also on the importance of trust in the community. So, now a lot of your work has addressed both of those, but why do you think trust is so important to develop a more equitable system of care?
Dr. Bhavan: Yeah, I think that's a great question. Trust is really, I think the cornerstone to improving how we deliver care in the United States—health care in the United States—and do so more equitably. The population where I work, if you think about the demographics, the majority of our patients that we take care of through Parkland Health and Hospital System, I'd say at least 75%, identify as Hispanic or African American. We take care every day of people that are either uninsured or underinsured and live in communities with multiple health disparities. So really when you think about serving the needs of this very vulnerable population, trust is at the cornerstone of everything in terms of being able to deliver effective care. And I think for a variety of reasons that, you know, vary from community to community, we have a system where there is broken trust and we're seeing it in various examples that, you know, I'll talk about today, including more recently, vaccine hesitancy.
And I think it's our responsibility, rather, as health care providers and health systems to really engage better with the patients and the populations that we served to identify those areas where trust is broken and find ways to effectively, kind of, bridge that gap. We address this sort of, you know, through multiple dimensions. And I think in recent years, the discussion around social determinants of health has really taken center stage. You know, there's increased awareness that it's not just pathophysiology of disease and medical treatments, but also recognizing the patient as a whole in the community that they live in, and what types of social determinants of health may affect the care that they're getting.
Dr. Brown: Absolutely, and I really want to get down to some of the really concrete examples, you have many of them we're going to be able to focus only, probably on three or four in the time we have, but I have to add to the mistrust that you mentioned and what we can do as health care providers. And one of those for our listeners is to be sure that we're all familiar in detail with the Tuskegee study in Chicago. I was, you know, not taught that in medical school and I find that many physicians and nurses really don't know the details of that study and have a lot of misinformation. And though maybe our patients won't share that it has added to the culture of mistrust. So, I know your work at Parkland has spanned many disciplines, but three examples of building trust and addressing equity really popped out when I was looking at the wonderful work that Parkland is doing. Can you tell us a little bit more about Annie's Place and Mommies in Need that was developed at Parkland?
Dr. Bhavan: Absolutely, you know, just to kind of clarify, Mommies in Need, that was actually in existence prior to the partnership that became Annie's Place at Parkland and I think it's a wonderful example of how social determinants of health, that conversation that we've started, you know, several years ago, needs to continue to evolve, to be all encompassing. Oftentimes when we think about social determinants of health, we think about food insecurity or housing insecurity, for example, or barriers to accessing care related to transportation. And several years ago, a wonderful woman, her name is Natalie Boyle, came to Parkland with, through one of my colleagues, Kimberly Cook, Dr. Kimberly Cook at UT Southwestern, who is an OB-GYN practicing physician and came to us talking about Mommies in Need and what they were doing in the community. And, you know, when you hear Natalie's story, it's very compelling, but she herself went through a very terrible health crisis with very young babies at home.
Her twins were very young. She had to have multiple surgeries and there was a cancer diagnosis and when she was going through the treatments and recognizing that not everybody has the resources that she may be fortunate to have had, she really became determined to do something about this. And Annie's place came from actually one of her friends who was not able to access regular child care for her chemotherapy appointments and so forth. And Natalie was kind enough to and generous to share her services, her nanny, with her friend. From that emerged Mommies in Need and thousands and thousands of hours of in-home child care provided by nannies through this nonprofit organization to help women be able to attend their chemotherapy appointments and so forth. When she came to us at Parkland, the idea was what can we do for some of the most vulnerable communities where they aren't able to go into the homes and the patients aren't able to access this care.
And again, I'm, you know, really fortunate to be working at Parkland. Dr. Fred Cerise and the leadership here, with the Center for Innovation and Value that I worked through recognize if there was a real need that we could potentially start to address and kind of understand better in that social determinants discussion around child care. So, Annie's Place opened in fact, right in the middle of COVID, November of 2020, and it has been a remarkable experience to see how people are accessing these services. Prior to opening the center, we were doing polls internally to see how are we doing compared to what little is in the literature. And I think the Kaiser foundation has a fantastic report from 2017, I believe, where they highlight, you know, that this is a reason why women, and it can be really men, any child care provider or dependent care provider but women when asked about, you know, accessing their primary care appointments or treatments and so forth.
One of the leading pauses of missing those appointments or delaying time to care was not having a safe place to leave their child. When we asked at Parkland and we were kind of looking around, we had Dr. Kim care had some medical students with her on this project they noticed, you know, right in the women's health area. So, in that OB-GYN sort of domain, you had little children in the waiting room. Sometimes if a patient had to go in to get seen, sort of handing off your child to someone you don't even know, you know, in the waiting room. Certainly, with COVID things really changed where they were no longer able to bring small children in. And so now you're perhaps trying to access prenatal care for your second baby and you don't have a safe place to put your child.
And so, there are just numerous examples of things like this happening. And as I was talking to, you know, Natalie Boyle, again, the work that she said is remarkable in the private sector for Mommies in Need. It was evident to me that this is something that is not specific to Parkland, that probably is more of a universal need and that when you think about sort of, you know, on an airplane, we tell people put the oxygen mask on yourself first and then the child. But here we have at times, you know, crisis situations, you know, with various sort of serious diagnoses, such as cancer, where people are actually postponing chemotherapy or necessary surgery because they don't have a safe place to put their child and that's really not a choice, really, that's a reasonable choice to ask people to make.
And so, Annie's Place has opened, as I mentioned, in a very challenging time, during COVID. And I’m very proud to say that the work that's going on there is really kind of highlighting an unmet need. And we're hearing stories of people coming in accessing not only services for crisis situations but also for preventive health. So, for example, breast cancer, we know that in communities of color, that we see breast cancer being diagnosed with a later stage. If we're going to encourage people to get their mammograms and if one of the barriers is not having a safe place to leave their child, you can now access a place like Annie's Place on Parkland's campus to be able to go and get preventive services as well. And the stories that I've heard from Natalie and those who worked there have just been remarkable. Ranging from a woman who was seven months pregnant and had not been able to access prenatal care because of a child care issue to somebody postponing a hysterectomy or even a surgery for tumor, because they didn't have a place, a safe place to leave their child.
Dr. Brown: That's just amazing. And I want to hear more details about the way you set it up, because I think some people don't think that, you know, a hospital that it can be done. But I really appreciate when you mentioned preventive care as an internist, there would be many times where the patient wouldn't be able to see me for their diabetes or their hypertension unless they brought their children or their infant. And then my nurse is cajoling a screaming child, or even worse if they're in for pap smear and you know, you don't want, the mom doesn't want the child or you know the 10-year-old, in watching this and trying to be discreet and it's awkward at worse and it's just, it is just impossible. And the choices that mothers have to make to avoid that is to not get health care. But how did you do it? Is it a space?
Dr. Bhavan: Certainly, it's my first experience really working with a community-based organization, health system partnership. And it's about kind of thinking about aligned vision and sort of the values and mission and trying to kind of work together from two different angles. What they bring to the table, Annie's Place expertise in child care and I'm probably not doing them justice by not mentioning that it's so comprehensive that it's not just that you drop your child off there and then you're able to get your, your care. But for example, if you were just diagnosed with breast cancer, I mean there were times when the child would be there when you're hearing it for the first time. And now when you drop off your child and you're going to get treatments, just chemotherapy, Annie's Place has a full-time play therapist that can work with the child while the mother is getting care in that scenario to help them deal with the terrible kind of stress issues that all of this can bring into a family.
And there's just so many other great, kind of, preventive things that they're able to provide where it's holistic care for the child as well. How we did it? We did it because I think, you know, when we were talking to Natalie Boyle, it was just evident that there was a lot of good being done in this domain in the private sector with what she was able to do with her nonprofit organization. It's also evident to me that you don't know what you don't know. So, if we don't ask the question, we can't really define the need, particularly among the most vulnerable populations. Without executive championship, it would've never really taken off. And there I'm really grateful again for Dr. Fred Cerise, his leadership at Parkland and creating the space for innovation and value to be forward thinking about what we can do for our patients differently.
Parkland was able to provide the space, physical space in an area that wasn't being used. And then Mommies in Need was able to come in and renovate that space with philanthropic support to really make it a very open inviting and welcoming kind of place on campus for families to want to access that care. And over time, that's really been thrilling, as we're seeing kids want to come to Annie's Place. In other words, excited that mom has a doctor's appointment because they get to come into Annie's Place. It's just a very wonderful sort of renovation that took place to really open up that area that was sort of an unused building into a very warm and welcoming child care center. So, they provide the child care services and they're largely funded through philanthropic support and they provide nutritional meals and some early childhood kind of initiatives on site.
There is a social worker that's able to actually think about how these social determinants oftentimes can correlate. So, you know, it's not often that you might go to a food bank and somebody asks you, do you also have childcare problems? But here we're able to say, look, oftentimes these domains kind of correlate. So, we're taking care of your child in this immediate need, but is there also food insecurity, housing insecurity, where we can at least try to think about how to point you in the right direction? And Parkland offers the space, the electronic medical record through Epic and some really wonderful work. Kristen Alvarez, on my team and Michael Harms really were able to kind of harness the power of Epic, which is what we use here, the electronic medical record, to think about not creating more work but working within existing workflows for nurses and social workers and care managers, to be able to place those referrals and work through all of the logistical issues to have a more seamless process from hospital or clinic into Annie's Place. So, there was a lot of work that went into developing those workflows and creating dashboards, and thinking about how we can improve upon the process. And then of course, the physical space that Parkland was able to provide along with very important logistical issues, such as environmental services for cleaning and security.
Dr. Brown: And just imagine the difference if a young woman with a young child is going for chemotherapy to go with their child, see their child happy and cared for and then distracting the mom and knowing that this is going to be worth going through all this chemo. They're not going to leave their child behind, they can bring the child with them. So, what a completely different experience that would be when someone's going through radiation or chemotherapy. That's fantastic.
Dr. Bhavan: And I just want to add that, you know, there has been a conserved effort, as I mentioned kind of briefly, about thinking about preventive services. And I think your experience as an internist really resonates. You know, there's sort of the things that are chronic conditions that we also neglect that over time can lead to just, you know, worsening outcomes. And whether it be sort of a mammogram or getting a COVID vaccination, you know, because you don't have the safe place of your child, you can now access Annie’s Place. And then respite care, you know, there's an increased focus on mental health issues, you know, and sort of how that factors into our health outcomes. And particularly, we already have the challenges of managing chronic diseases and multiple issues in the household and they're able to provide respite care as well. So. they've really done a great job at expanding those services.
And it's giving us an opportunity to do some qualitative and quantitative sort of mixed methods research to understand the experiences better from the women's perspective that are coming in to access the services and also be able to ask women who don't come in to access the services to what are the barriers, what are some of the cultural issues, perhaps there's trust issues there. And then over time to think about how does this make an impact in terms of delayed timed treatment and some of the more hard clinical outcomes like this, or postpone surgeries? And my hope is that over time we can really make a compelling case that it is worth the investment for other hospitals to do something similar to meet their local needs. And in some ways, I think of it almost like the Ronald McDonald house, a bit in reverse. But we see those, kind of throughout the country.
Dr. Brown: So, Dr. Bhavan, I'm really glad you brought up the COVID vaccine. This is an area of interest for me and the vaccine hesitancy that was prevalent before COVID, but what we're all living with now and impacting all of us, especially health care workers. So, how do you approach that really level of mistrust or hesitancy, especially as it relates to COVID?
Dr. Bhavan: It's been quite a challenge. I think COVID has really sort of highlighted the trust issue, particularly around vaccine hesitancy that we've observed, particularly as infectious diseases provider, but I know internist primary care physicians we've seen for years with influenza. And, you know, I'll tell you briefly about some work that we did there to kind of address that in a very tangible way and think about how we can engage with the community to improve trust. And it really kind of starts with the community health needs assessment. You know, our nonprofit hospitals, we're supposed to be every few years coming up with these community health needs assessment goals and thinking about how we're going to creating actionable items to improve care in some of our most vulnerable communities. And what I noticed the last couple of cycles is that we see a pattern that just kind of reemerges with something like influenza.
And so, you know, I'm in Texas and one of the things that I say, you know, all the time is, hey, but, you know, influenza vaccine is free. We may not have Medicaid expansion, but we do have certain things such as influenza vaccination that is free to all. And when you see almost twice the mortality in some zip codes of south Dallas compared to more affluent areas in north Dallas, due to influenza and pneumonia, defined so well with the sort of heat mapping, if you will, of our zip codes, it's alarming and you want to, you have to ask yourself, why is this happening? And so, the work that we did with the community was with a largely Hispanic community. And I'll note that with ... if you look at the Center for Disease Control data over the last decade, Hispanic communities, when compared to Black and white communities, consistently have the lowest rates over the last decade of influenza vaccination.
So even before COVID-19. And the work that we did really centered around working with high school students, where there was already some trust. And one of the physicians here at UT Southwestern had been going out to a school in one of the communities with multiple health disparities here in south Dallas and over the years have invited me to come out and speak to the students about careers in health care. These high school students were oftentimes first generation to get to where they were educationally in high school or be college bound. And because they worked in this work study kind of framework at Cristo Rey Dallas school, they would spend one day a week in a work setting. And then the other four days went to school. Well, the small group that was very interested in health care, it was easy enough to talk to them about what it was like to be a physician, a female physician.
But when I asked, you know, who had a flu shot this year, and it was respiratory season, very few hands went up. And when I showed the heat map, you know, to the kids from the community health needs assessment, one of the high school students, I'll never forget, a junior said, well, Miss Bhavan, this is health segregation. You know, to see that such a stark difference in we're going to gain mortality from something that's potentially preventable, you know, vaccination. Which then led to sort of really digging deep into why is this happening and thinking about what the barriers were, what the trust issues were, and working with the high school students that wanted to, you know, be doctors and nurses some and saying hey, rather than you kind of following me, why don't we follow you really into the community to think about what the local issues are because the vaccine is relatively ineffective if it's just sitting on a shelf, we can have the right vaccine. This is before COVID.
And so, it was a small pilot where I went to the health department and asked for some doses of flu vaccination in that particular zip code, they were tracking how often, you know, people are getting vaccinated because it's part of what the public health department does. And needless to say, it mirrors what we see with the CDC data. By the time we got the vaccine to do this event with high school students and the community fully engaged and kind of leading it, co-creating the whole event, if you will, it was already January of 2020, right before COVID hit and you know, sort of tail end of the flu season. The expectations were low and when I asked for 400 vaccines, people thought, well, that's probably being over ambitious. It's really the tail end. And we usually see about 50 or 60 people show up for these events.
The difference was to really work through what the trust issues were to take these really smart young people that want to go into health care and empower them with good knowledge so they can help dispel misinformation. And for a small amount of money from an endowment fund, I was able to put two of these high school students on radio and they were on Spanish radio station delivering the co-creative message. They told me what sources of trust were. Families from the focus groups let us know it's the church, it's the school, for example. It's not necessarily listening to NPR or seeing a radio advertisement that we would have in other areas or a billboard, for example. And so, working with them and doing that led to one of the most effective campaigns that we published the data on it in health equity.
But January of 2020, we had more than 400 people show up with just a real simple community-engaged approach.
Dr. Brown: Wow, that's amazing.
Dr. Bhavan: And the challenge really was to see if we could continue that work through COVID-19 with all of the issues related to social distancing and all the precautions that were necessary. And I'm proud to say with these high school students and really kind of going into the community and working with the community, we were able to vaccinate more than 1,400 people under 16 hours, oftentimes on a Sunday. And then talk to people that showed up and find out that sometimes they had never had a vaccine before. This was their first time. And now they're asking, are you going to do this again, next year? What I was really proud of was Harvard Medical School Center for Health System Transformation asked us to give a talk about how we did it, because now COVID-19 is the issue.
You can kind of change out influenza for this. And I took one of these high school students who wants to be a doctor someday; she was my co-presenting faculty for the Harvard talk. The kids, if you ask them, they're like oh, we're saving lives, and they really believe that there's some importance to this work. We call them health ambassadors. And it was about, as Dr. Burwick, Don Burwick says, transferring knowledge, not people. We don't need more doctors and more nurses to go into the community. We need to transfer knowledge and build that community from within. And I think that this is sort of a time that we're in where COVID-19 has really just highlighted so many pre-existing issues related to health disparities and has opened up ways for us to think about how can we improve health equity and really continue to engage down the path.
Dr. Brown: Well, you have been an inspiration and I look forward to speaking with you again, thanks so much for joining us today, Dr. Bhavan. Thanks to you, the listeners, for joining us as well and taking time out of your incredibly busy day. For more resources on building trust and addressing equity and strengthening your practice, please visit the AMA STEPS Forward® website at AMA stepsforward.org.
Outro: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.