Speaker: Hello and welcome to the AMA's 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's STEPS Forward® Program is open access and free to all at stepsforward.org.
Jennifer Mathews: Hi. Thank you everyone for joining us today. My name is Jen Mathews and I'm the communications manager here at the AMA. And joining me on the podcast today, we have two guests, Natalie Boyle, founder of Mommies in Need, a nonprofit that provides childcare for parent patients through a variety of programs. And Dr Kavita Bhavan, chief innovation officer at Parkland Health and associate professor of infectious diseases at the University of Texas Southwestern Medical Center. Natalie, Kavita, thank you so much to both of you for being with us today.
Natalie Boyle: Thanks for having us on.
Kavita Bhavan, MD: Yes. It's a pleasure to be here.
Mathews: Oh, good. Well, it's a pleasure to have you. So let's jump right into it. I'm so excited to have this conversation today. We are here to discuss how Parkland and Mommies in Need came together to address a key social need in the Northern Texas community where you both reside—free, accessible, drop-in childcare during medical appointments or treatment. I would love to hear how this partnership first came about.
Boyle: Well, I'll go ahead and just start off in terms of how Mommies in Need got going and then we can talk about how we kind of worked together. So I'm a cancer survivor. I had 18-month-old twins when I got diagnosed and I just lived through how difficult that was, even when I had every resource possible available to me. I had family and we were able to hire a nanny and all of those things. And then a friend of mine got diagnosed with colon cancer and she had a 2- and a 4-year-old, and she didn't have those resources available to her. I remember being in her hospital room and her just saying, “Well, I guess I'm going to just have a friend watch my kid on chemo days and I'll deal with it myself the rest of the time.”
And I just viscerally was horrified by that. I didn't want her to have to go through it. And so I just offered to send my nanny who I didn't need anymore to her. And we started a crowdfunding campaign to pay for it. And what happened very quickly is we discovered that not only were people willing to help provide this kind of care to chip in and pay for it but that I was contacted by so many people asking how they could do it for someone they knew and loved. And so we decided to form Mommies in Need into a 501(c)(3) and we started taking on additional families, helping more people and hiring more nannies. And so the program that we operated for the first five years is our in-home program, and that's where we can send a full-time nanny into a client's family home for up to six months at no cost to the family. And it is that same nanny. The nannies are employees of the company, they go there every day.
And we saw firsthand just the incredible impact that this had on families. We were never cancer-specific. About 60% of our families are cancer-related but we had everything from organ transplants to strokes, a lot of high-risk pregnancies where you see moms who are—they're supposed to be on bed rest but she can't be on bed rest if you have a 2-year-old, right? So that was a lot of what we saw.
And we came to a couple of things a few years in which was number one, that care is wonderful, but it's very high cost and it's hard to scale, right? Because you have to have a nanny for each family. And the other piece was we started saying no to families for really heartbreaking reasons. We can't send a nanny into a family's home if they don't have stable housing. If they have too many family members living in the same home. If there's any kind of domestic violence situation. We have to be careful of the safety of our nannies.
And then for some families, they didn't need full-time care—they just needed care for those medical appointments. And so that's when I got introduced to Dr Bhavan. Dr Bhavan, I'll let you take it over from here just how we were introduced and sort of gelled immediately and would love you to tell your part of the story of how that came about on your end.
Dr Bhavan: Yeah, I think we were just incredibly lucky to meet and to connect through a mutual colleague and Dr Kim Kho, who was working in the innovation center with us at the time. Almost immediately it became obvious to me that there is a real potential here to make a difference and to address a social determinant of health need that hasn't really been addressed before, at least to my knowledge in this kind of way. And to really kind of think about what can we do that's actionable to improve access to care by addressing this need?
So it was sort of just a gift that came down to us through Natalie. And hearing her story, as you can imagine, was just as compelling the first time I heard it as it is every time she shares this with us. To have gone through that experience firsthand and to have been on the side where she was receiving care and see where the limitations were and thinking about how many more women are in that situation and potentially are facing increased barriers for some of the reasons that Natalie just explained in terms of housing and so forth.
So we just got really excited. Our Center for Innovation and Value at Parkland, very lucky to have the leadership of our CEO, Dr Fred Cerise for Parkland, embraced this idea and wanted to partner with Mommies in Need to think about creatively how to develop a program that would be on campus, so, on Parkland's campus. Where we eliminate one more barrier where patients are coming in to get their care—they don't have to drive or drop their children off somewhere—and create a facility that was going to hopefully improve access issues for caregivers who neglect their own medical appointments and procedures and needs not infrequently because of a competing interest, which is equally important of a dependent child who needs a safe place to be cared for while the adult is receiving medical care.
Mathews: Yeah, definitely. So that's such a fascinating background. So how did you get from that initial genesis of the idea to where and what Annie's Place is today? What were the first initial steps? How did it evolve, et cetera?
Boyle: Well I think Kavita talked about something that was really instrumental, which was getting the top leadership on board right away. So the first piece was getting that go-ahead of, yes, we love this idea and we're willing to work on it. And then we got a lot of people in a lot of meetings and just tried to figure out—it took a couple years to really get to the place where we knew—we had to find a suitable location because a childcare center has to be on the ground floor, it has to have certain kinds of exits. There were all of these kind of limitations. And we worked with the great team at facilities to help get creative and find a building that wasn't being used. And so it really was a very collaborative effort.
And we found this space and we started remodeling it and then it was ready. It was November of 2020 when the building was ready. So we started construction before the pandemic and then construction continued and we were like, OK, we're going to try opening this. It was very much a collaborative effort and it was very much a lot of people getting really creative and being open to exploring ideas. And Dr Bhavan, I don't know if you have anything you want to add on that piece.
Dr Bhavan: No, I think that's exactly right. I mean there's no blueprint for this and there's no precedent to kind of say, this is how we do this—it's not like we're building a clinic. This is really brand new. And I think what Natalie and her team brought to the table was a real partnership with a community-based organization that understood how this care could be effectively delivered. And so it was a lot of learning from each other. I mean, the health system may have been new to them, so too was working with the community-based organization like this new to us. So I think staying open-minded about what those needs might be that are unique and how do we tailor them to fit into a health care setting, all of that became really important. And it was an evolution, but a challenge at the end to open, as Natalie mentioned right during the pandemic. It's just been amazing to me to see how things have taken off in spite of those challenges.
Mathews: Definitely. So the name of the center is Annie's Place. Why don't you give our listeners a little bit of context about that?
Boyle: Yeah, absolutely. So Mommies in Need is the name we started with because we really started with helping stay-at-home moms. That was what we began with. And we wanted to keep that legacy but we wanted it to be more inclusive. And so we started working on, OK, well what would the name of this childcare center be? Because it doesn't just serve moms, it serves dads and grandparents and foster parents, and all guardians. And unfortunately, so the mom I was talking about, my friend in that hospital room, that's Annie. Annie got through that first round of cancer treatment and a few years later she had a recurrence. And unfortunately, she passed away.
Her family did a kind of celebration of life a year after she passed. And that was right about the time we were trying to figure out a name for this place. And so we worked with her family and we decided to name it in her honor. It makes me really happy because she loved babies and we have babies in there every day. And it's just a really nice way to honor not only the first mom we helped but kind of where we came from as an organization.
Mathews: Yeah. Oh, what an incredible honor that is, too.
How exactly does the structure of Annie's Place work? I mean on a simplistic level, yes, it provides childcare for patients who are seeking treatment at Parkland, but in practicality, how does that work? How do you set that up? How do you handle communication between Annie's Place and Parkland and all of those moving parts that I'm sure go into making this system work?
Boyle: So the way we set it up was really that we collaborated, but we each kind of had our sphere that we owned. And so Parkland has provided all of the resources that they would for any other clinic building, so that we are on their IT network, we're integrated with their security team, with their janitorial EVS services. There's the constant points of connection and then Mommies in Need, really our specialty is running the childcare. So it is a licensed childcare center and there were a lot of things that kind of developed as we went along.
Originally we were going to get what's called a parents-on-premises exemption, but in those kinds of childcare centers, you can only stay for four and a half hours. And it was when we met with the oncology team and they said, we can never get our oncology patients, if they're in an infusion, they could be there eight hours—we can't get them in and out in four and a half hours. And so we developed this alternate care license, and one of the ways that works really well is that we are actually connected into the Epic system, the EMR system at Parkland. And that took a lot of doing, and Kavita's team was just amazing. But that has a huge amount of benefits and I'll let her talk about some of that in a minute. But on our side, we can see when a patient's appointments are coming up. So when they call us for their first appointment, we say, hey, we also see that you have it on this day, this day, this day at these different clinics. Would you like to book childcare for that?
There's also a little flag that we put on a patient's chart, which is really important because we have a lot of families that come in—so especially our high-risk pregnancies—they drop off the kids, they go into a scan, turns out they have to have an emergency C-section and we have their kids. So we're notified, we have that flag on the chart so we're notified if there's a change in status. So it's really kind of a great way for us to work really collaboratively with the hospital. And Dr Bhavan, do you want to talk anything about the dashboard and how we got to that place?
Dr Bhavan: Yeah, I think what Natalie just alluded to with the power of the electronic medical record, it was just really important when we're starting this endeavor to harness that potential. And for multiple reasons, I mean from a workflow perspective as well as from a quality and process improvement perspective, to be able to keep track of how we were taking care of our patients and utilizing this new resource. Dr Kristin Alvarez and Michael Harms on our team were very, very instrumental in working through all the nuances of figuring out what kind of ways we could connect with Annie's Place, where the right information was being communicated in a timely manner that was also appropriate in terms of what medical record and workflow. With all those challenges they did face, they really were able to figure out a streamlined way to safely and effectively communicate information that Annie's Place would need to serve their clients. And at the same time allow us as the providers on the health care system side of the equation to identify people that may be at risk of missing appointments and so forth because they don't have a safe place for childcare.
An example of that is MyChart. There are mechanisms in place for patients who engage in MyChart to be able to say in a survey kind of format that they missed an appointment due to what reason due to childcare, which would then allow us to identify this particular group of patients and let them know about Annie's Place and share those resources with them.
Similarly, dashboards were kind of created to think about, OK, how are people utilizing this? Where are they coming from? What parts of the hospital are they coming from? A majority of the patients were coming from women's health where it was a very socialized concept, this new initiative.
And so we did have patients, which was really surprising for me to see and hear, and it probably shouldn't be because it happens everywhere that women that may be seven months pregnant and have never had a prenatal care visit because they don't have a safe place to put their other child. You may go in for some sort of imaging test and then find out that you have to have an emergency C-section. I mean, these are real challenges you can imagine in real time. It became a safe place for our patients to access what was, I believe really by word of mouth, quickly recognized as a quality, safe environment to drop off their children. Almost 70% of the patients that have accessed Annie's Place have never left their child with any kind of outside provider. It's just family, friends. And so this is sort of a trust issue, too. How do you build trust, especially with a collaboration that's on the health care system campus? It's a ripple effect, right? The trust in the care that you're about to engage in and that the health system cares as well to provide this for you.
So that's been sort of the ongoing challenge, trying to figure out how we can optimize these resources and identify the right groups of patients that can benefit from these resources.
Mathews: So it leads me perfectly into my next question because I was going to ask that in general. Dr Bhavan, on an earlier podcast that you appeared on with us, we talked a lot about the issue of trust, especially when you're doing outreach to different communities and trying to establish that rapport and that reciprocal communication. How did you go about establishing trust? Because I recognize that that's an enormous component, particularly for people who maybe traditionally avoid seeking health care for the issue of childcare and a number of other issues that may be involved, and that they have never left their children with someone outside the family before, and probably a list of other issues as well. How have you addressed those issues as they've come up?
Boyle: Yeah, we knew that the trust piece was going to be a barrier. We really designed everything very intentionally. So first of all, the center itself is absolutely stunning. I mean it is way more beautiful than the preschool that I paid a lot of money to send my kids to. It's bright, it's open, it's tons of windows. We wanted everything very transparent. We're not hiding anything.
The other piece is the hiring. So we are not a traditional childcare center. We have different children every day. The children are not used to coming to childcare. It's the first day of school every day. They're in and out all the time. We're not an IKEA where you drop your kids off and they're just there free playing for a few hours. The kids are put into classrooms by age, they're getting an educational experience.
But not only that, every single staff member is trained in trauma-informed care and play therapy. We have a full-time play therapist on staff that's able to provide resources for the children that come in and aren't able to regulate. So she can do one-on-one sessions with kids that need that or actually come in and do classroom and crisis interventions. So if a child just really is acting out because they don't know how to be away from their parent, we have a resource for that child.
And then we made sure that we had a very diverse team working at the front desk. All of our teachers, we have multiple languages spoken, almost everyone is bilingual in Spanish. And so when people came in the first thing that they do is meet our front desk team, who are just phenomenal.
And it took a while. It took a while to build up that word of mouth. We were also in COVID, so we were like one child per room for the first three months. It also helps that they already have a trust in Parkland. And so it was their nurses, their clinicians that were saying, “please send your children to Annie's Place.” And so it's kind of this back and forth of making sure that because Parkland's standard of care is so incredibly high and our standard of care is so high that that just built trust back and forth between the two entities, I think.
Mathews: That's great. And we interviewed both of you for a success story that's featured on our website as well, and I'm going to link to that in the description portion of this episode.
Dr Bhavan, Natalie, you both shared a few incredible stories about patients and their experiences that they've shared with you about how having Annie's Place available to them, how that impacted their health care journey. Would you mind sharing a couple of those?
Boyle: Absolutely. One of the stories that I share often because it is just such a clear view of why this is necessary, we have a mom who has a lot of medical conditions, including sickle cell anemia. And this was during the height of COVID before she kind of knew that we were around. She thought she was going in for a shot and she didn't have a safe place to leave her 6-year-old son, but she knew she had to get it because she can't be a mom if she's not treating her health. And so she left him in the car, and this is in the Parkland parking garage, which is a giant area. She told him don't open the door for anyone no matter what. Well, she got in and they did a blood test and she was critically low on hemoglobin to the point that they had to rush her back for emergency blood transfusions.
And she said, “But my son's in the car.” So someone from the hospital had to go out and first find the child, get him out of the car. But then, unfortunately, because of mandated reporting—it was a child left in an unsafe situation—and so CPS had to get involved.
And what was really beautiful—and I love the ending of this story cause the beginning of it's so heartbreaking—is that they started coming to Annie's Place. Not only was mom able to get all of the treatments that she needed to get, but the little boy, we were able to put him in play therapy. And so he worked through not only that trauma but a lot of other traumas that came from having a sick parent.
And then we stopped seeing them and we hadn't seen them for a long time. And mom came in and we said, “We miss you—we used to see you all the time.” And she said, “Well, I don't have to come to the hospital as much anymore because I've actually gotten on top of my health stuff and so I'm better.” And I think that's just a perfect example of what we're able to do.
Dr Bhavan: That really is and there are countless examples of surgeries that are canceled at the very last minute. When you're dealing with patients, particularly with terminal illness or cancer, for example, it really makes even little sense that we have to delay our own care that might prolong life in the immediate sense because you have those competing interests of where can I safely leave my child? So when you think about missed appointments, time to things like chemotherapy, time to things such as surgery, say for breast cancer, things like this, they all become really, really important.
And I think what's become abundantly clear as I hear Natalie tell stories of our patients that have accessed Annie's Place is that we're just kind of touching the tip of the iceberg. It's not a fair choice to have to make—do I choose health care or childcare if I don't have a safe place to leave my child? And the ripple effects can be profound in so many different areas as Natalie alluded to beyond just cancer, primary care, preventive care needs.
One of the things that I'm proud of is that using the breast cancer example, we have been able to create a system effectively where when people are getting scheduled for say a mammogram, they'll be asked, is childcare an issue? And if childcare is an issue, advised at the time of making the appointment that there's this place called Annie's Place that you can drop children off. And when you think about women of color in particular being diagnosed later stages breast cancer and a lot of the national initiatives around improving screening and so forth, this is just another just practical, important component to think about. Do they have young children and do they have a safe place to drop them off? Is that part of what's hindering going in to get that mammogram?
Another great example is I know Natalie and her team, they were able to, during the pandemic, really address COVID vaccinations and say, if you need a safe place to drop off your child while you get your COVID vaccine.
Boyle: And that's something that was really an evolution. So, our original mission was about parents in a health crisis. And then I explained we went from just parents to all guardians. And then we started realizing when we served this population that people were getting to a crisis because they weren't getting preventative care. So we started opening it up to basically any medical appointment that you need, if you need childcare for it, that's what we're here for.
About four months into opening Annie's Place we got a call from the NICU and they said that their parent visitation rates had dropped by about 40% because siblings were no longer allowed in the building. And so they said could you watch those kids? And we said absolutely. And so we started taking care of the siblings of NICU babies. In fact, we've had multiple sets of twins where one twin is in the NICU and the other twin needs a place to be so that mom can be at the NICU with the baby all day.
And then the other thing that we started recognizing was that there was a need for backup care for the hospital staff. Especially COVID was really hard, but it also taught us a lot of things much quicker than we would've learned them otherwise. And so we had clinics contacting us and saying, “Well, our clinic's going to close because we don't have enough nurses today. Could you take a couple of those kids?”
And so that's when we really did a complete revamp of our mission statement. So it's now caring for kids so families can access health care and anywhere there's health care and childcare need, that's sort of what we're here to do. That came from just learning these lessons as we went along and really wanting to be across that entire spectrum of care so that people can get access to the health care that they need.
Mathews: It's amazing in a short period of time hearing how much the center has evolved to meet the needs of the communities where they are. I mean that's the goal—to be able to continuously listen and communicate and respond as different needs come up and other needs are met. And it's beautiful. It's beautiful and it's inspiring and I imagine it's going to be inspiring to some of our listeners, too.
So that leads me to probably the biggest question of all that I would have if I was listening to this is. This sounds amazing—I would love to do this at my health care organization. What advice would you have for people? I imagine just even wondering where in the world do you start, how do you get the conversation going? How do you engage leadership and get them to have buy-in? Funding, I'm sure, is a big question that a lot of people would have. Any advice based on your own experiences, Dr Bhavan and Natalie, that you could share I'm sure would be very welcome.
Dr Bhavan: Yeah, I think part of what makes it a little bit easier perhaps today than a few decades ago is we're increasingly aware of social determinants of health and looking at how do we care for other needs that the patient might have. Our mission is to take care of their health and well-being and so we talk about food insecurity, we talk about housing insecurity, and this is just now, I think, another domain that we're just touching on.
But we were very lucky to have Natalie as the CEO of Mommies In Need having developed something that was already working in the community kind of partner with us. So we had a tremendous advantage there. But I think from a health systems standpoint the argument can be made a little bit more perhaps with ease now than before because of the increased focus on social determinants of health.
But executive championship is essential and you need to appeal, I think to leadership that this could potentially be sort of like a Ronald McDonald House. We've seen today, Ronald McDonald houses are on several different health care system campuses when you go across the country. But it's sort of that kind of concept about families and care and how sometimes just having that safe place to be now in this situation, it's the parent getting the care and the child that's in this caregiver setting.
One thing that I would add also is that trying to maximize opportunities across the spectrum, not just looking at one particular need, such as they missed surgeries, but thinking about things from surgery to preventive care to special populations like cancer needs. I think you can start there by getting a sense of where this might fulfill a void in your health system. Who do you serve? What's your mission? Where are those needs?
And then talking to women—I don't think we do enough of that in terms of surveys. And really, I shouldn't say just women—caregivers—but the Kaiser Family Foundation put a survey out several years ago that showed that this is one of the leading causes of missed appointments for women in particular that really hasn't been addressed. This is not something that's ubiquitous to see an Annie's Place in different areas. And there is an investment and I think it's sort of both from the health care systems side, but also a solid community-based organization side to make this successful.
Boyle: And I'd also like to say, so Mommies in Need, we are already in process on creating a couple of other Annie's Places in other locations. It is something that we believe needs to be at every hospital. I mean it's a solvable problem, which is kind of beautiful. And we know that we can't necessarily do every single hospital that there is but we welcome any health system that is interested can contact us through our website. It's mommiesinneed.org and if it's not something that we can do we can absolutely help advise, help give some data around what this does for patients. We would be happy to help in any way to get more patients the ability to access their health care because of childcare.
And we know the need is huge. I mean, in our very short time open, we've already served more than 5,000 medical appointments, about 17,000 hours of care. It's definitely something that's a huge need and I think makes a big difference. I'll also say it makes a difference in the way that the patients feel about how their hospital cares for them. We hear all the time, they love the child's care, but they also feel valued as a person because the hospital has made it a priority to say, we understand that this is a barrier. And so, it's really beautiful the kind of community that it creates when you're doing this.
Mathews: Yeah, absolutely. As a mother myself who's had my own health issues in the past and has dealt with these issues and I have friends that have dealt with these issues, it's huge. So thank you so much, and thanks for sharing your time and your story with us. And we will link to Mommies in Need in the descriptive part of the episode as well, Natalie, because that was a wonderful offer and I imagine there will be some people that will take you up on that. At least I certainly hope so.
Did either of you have anything else that you wanted to share before we end our time together?
Dr Bhavan: Yeah. I just want to add the work is ongoing. I think that as we talk about other health systems kind of looking at this as potentially a model, one of the things that people are going to want to see is data—and outcomes data. So we're working on that and we're working on thinking about the qualitative components and sort of also some of the clinical outcome components to measure success for others to kind of see what that has been, what that sort of return on investment could potentially be. Research is being done. We've got folks that are really involved from public health and from the medicine side working on various projects. So I'm looking forward to getting that data through peer-reviewed publications and having that out in the literature to start to show, demonstrate that there can be some real meaningful outcomes, both clinical and from the trust standpoint, and that your health system cares for you. But we need to continue that process to figure out where we can improve, where we can expand and share that data in a peer-reviewed literature space.
Mathews: Absolutely. Well thank you both so very, very much for being with us today.
Boyle: Thank you so much and thanks for having us on. This was so fun.
Speaker: Thank you for listening to this episode from the AMA's STEPS Forward® podcast series. AMA's 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.
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