Children and teens who bump up against barriers to medical care have more than their health at stake; they may miss or even drop out of school if they aren’t compliant with school requirements for vaccinations, physical exams and various health screenings. Comer Children’s Pediatric Mobile Medical Unit (MMU) travels to several Chicago elementary and high schools most days of the week to provide the primary care that allows kids to stay enrolled in school and to connect them with providers at Comer Children’s or in their communities for routine primary and subspecialty care.
The MMU—an RV with two full-size exam rooms—also attends to children’s and teens’ mental health. A social worker with Comer Children’s violence intervention program, Healing Hurt People–Chicago, provides specialized support in the MMU to kids who are recovering from the psychological and physical trauma of violent injury. A Comer Children’s social worker also provides mental health counseling on site at two Chicago schools. The mobile unit reaches even more kids with its health education classes. In the past year, a nurse practitioner provided health education for more than 850 students. And a collaboration with the Comer Children’s child psychiatry residents resulted in mental health education sessions for students and teachers.
When the MMU is not providing direct primary care to school kids—in 2017 there were over 750 medical encounters at schools—it is out in the community providing HIV and STI testing to teens and young adults, resulting in over 200 additional encounters. “We are breaking down barriers to care by going to where children and adolescents are, providing primary care, connecting them to needed medical services or helping them re-establish care with their primary care providers,” says Icy Cade-Bell, MD, medical director of the Pediatric Mobile Medical Unit.
Approximately 5,000 children in Cook County are wards of the state and live in foster care, now known as youth in care. These children have much higher rates of acute and chronic health conditions, mental issues and sporadic health care than the general population, says James W. Mitchell, MD.
Mitchell serves as medical director for both Comer Children’s ambulatory pediatrics and HealthWorks of Cook County. In the latter role, he is responsible for ensuring that youth in care receive timely, high-quality medical services, including an initial health assessment within 24 hours of being taken into protective custody, a more comprehensive evaluation within 21 days and the assignment of a primary care provider.
As he began auditing the quality of health care for youth in care, Mitchell found that providers and caseworkers often misunderstood the purpose of the encounters, which meant that children weren’t always receiving important services, such as hearing and vision screening. In addition, there was a lack of documentation guides for providers, as well as feedback after providers completed the evaluations of youth in care.
In response, Mitchell consolidated the number of providers by creating a dozen network care sites in hospitals and emergency rooms across Cook County. Each site now receives orientation training, as well as feedback when health services are completed. As a result, more than 86 percent of youth in care in Cook County are now aligned with a network provider who has received the special orientation, compared to rates of 45 to 50 percent in prior years. In addition, clinically oriented audits and audit tools effectively monitor the services received by youth in care and identify sites needing reorientation.
New documentation tools detail expectations for providers and help child welfare workers more easily identify the services rendered and monitor provider compliance. Since these tools were put in place, vaccine compliance rates have risen from 70 to 86 percent. Standardized medical forms also have improved detection of chronic diseases in children. Asthma detection rates for youth in care are now at 15 percent versus the 4 percent usually found through school physicals.
Mitchell has positively impacted the health care of children in custody not just in Cook County, but throughout Illinois. Working with the Department of Children and Family Services (DCFS), he led an effort to include clinical health care data in the Statewide Automated Child Welfare Information System. He also helped create an electronic printout of the Health Passport, a child’s medical record for caregivers, to reduce the gaps in health care service.
“A strong component of my efforts has been quality improvement supported by strong data,” Mitchell says. He found that 45 percent of youth in care switch placements or providers within the first year of custody. This means DCFS and HealthWorks may not know where a child is receiving medical care and will likely send the child’s medical records to the wrong provider, resulting in missed or duplicated health services.
Next year, HealthWorks is launching a new service, the “medical home visit,” to facilitate a compassionate transition of health care for children within 60 days of a change in placement. “This is expected to provide critical information for new physicians and reduce errors, redundancies and gaps in care,” Mitchell says. “We can’t let these vulnerable children slip through the cracks.”