From ATLANTA Medicine, 2013, Care for the Underserved, Vol. 84, No. 2
By Debra Hughes, MS and Yasmin Tyler-Hill, M.D., FAAP
Imagine you have no home. Your daughter is sick. Where do you take her?
For most homeless women, the local emergency room is the healthcare provider of choice for one simple reason: they have no other choice.
For women at the Mary Hall Freedom House – who have previously lived on the street, in tent cities, with friends or in their cars – their children have Healthcare Without Walls: A Medical Home for Homeless Children.
Healthcare Without Walls is a medical home with both heart and passion, and its most passionate proponents are I. Leslie Rubin, M.D., president and founder of the Innovative Solutions for Disadvantage and Disability (formerly Institute for the Study of Disadvantage and Disability), an Atlanta- based private, not-for-profit institute, and research associate professor in the department of pediatrics at Morehouse School of Medicine; Lucy Hall-Gainer, founder and president, Mary Hall Freedom House, Inc.; Yasmin Tyler-Hill, M.D., interim chair of the department of pediatrics at Morehouse School of Medicine; and Janice Nodvin, program director for ISDD and administrator of the Healthcare Without Walls Project.
In areas of affluence, there are pockets of poverty. For Dr. Rubin, this was most telling in the homeless children he treated with developmental disabilities including cerebral palsy, one of his areas of specialty. He found that children who are homeless are at high risk for adverse health, developmental, educational and social outcomes because they are likely to have been exposed to stresses before, during and after birth and also face multiple physical, emotional and social hazards. In addition, children treated in the emergency room do not receive comprehensive care, including immunizations or health or developmental screenings.
For Lucy Hall, her experience was personal. Her mother, Mary Hall, for whom the program is named, died of alcoholism when Lucy was six years old. She left seven children, some of whom later lost their lives to substance abuse. Lucy herself abused drugs and alcohol for 10 years, but when she became pregnant with her daughter, she became sober and to date has helped more than 3,500 women and children break the cycle of generational addiction, poverty and homelessness.
And for Dr. Tyler-Hill, it simply made sense to provide healthcare services for children who otherwise would have none, except for trips to the emergency room.
Their collaboration began when a Mary Hall Freedom House board member told Dr. Rubin about Lucy Hall; Hall subsequently attended a “Break the Cycle” conference put on by ISDD. When she met Dr. Rubin, they decided to work together to improve the health and well being of the children living with their mothers at the Mary Hall Freedom House.
“From the day I met him, I kept telling him about the services that these children needed,” Hall says. Drs. Rubin and Tyler-Hill “fell in love with the concept,” Hall adds, and they decided to seek a grant.
On March 1, 2010, the Maternal and Child Health Bureau of the U.S. Health Resources Services Administration and the American Academy of Pediatrics awarded a five- year, $250,000 Healthy Tomorrows grant to the ISDD, for Healthcare Without Walls: A Medical Home for Homeless Children, the first such grant awarded to Georgia in 17 years.
The goal of the Healthy Tomorrows grant is to provide seed money for an unusual idea that will flourish through involvement from community partners. Healthcare Without Walls is now in its fourth year collaborating with the Department of Pediatrics at Morehouse School of Medicine, Children’s Healthcare of Atlanta – Hughes Spalding Hospital (CHOA), and the Rollins School of Public Health at Emory University to provide a medical home for children, both at the Mary Hall Freedom House in Sandy Springs and CHOA Hughes-Spalding clinics. In addition, they are working with Childkind (a social service and support program in Atlanta) to train mothers in health literacy so they know when their children are sick and how to navigate the healthcare system.
The program employs the American Academy of Pediatrics Medical Home practices and Bright Futures guidelines to help ensure this group of vulnerable children receives healthcare that is consistent, continuous, coordinated, comprehensive, community-based, family-centered and culturally sensitive.
“Our goal is to try to build into our program a sense of continuity, to build into the lives of the women and children confidence and empowerment and to redirect their energies so they focus on their children, rather than the lifestyles into which they had drifted,” says Dr. Rubin.
The mothers who reside at the Mary Hall Freedom House – which is, in fact, several residences throughout the Atlanta metropolitan area comprising emergency, transitional and permanent housing for homeless women – love their children and try to do their best for them, says Dr. Tyler-Hill, who runs the Mary Hall Freedom House and CHOA clinics. But most are struggling with the effects of psychological, physical and sexual abuse; unmet mental health needs; and self- medicating substance abuse.
In some cases, the abuse – and substance abuse – is multigenerational, and the mothers may never have learned tactics to care for their children. A two-year-old girl with behavioral problems was diagnosed as hard of hearing after her mother failed to pick up cues she wasn’t acting normally, Dr. Tyler-Hill says. A boy of six who was incontinent and had undergone extensive testing in the emergency room with normal results was taught to ask to go to the bathroom and his mother advised to be less fixated on his behavior, with successful results.
Some women may have limited formal schooling. Others may be frightened they will be judged to be unfit and their children will be taken away. Still others may have been incarcerated and are being reunited with their children. Women who participate in the behavioral health program offered at Mary Hill Freedom House are either recommended or commit themselves to the program to end their substance abuse. According to Nodvin, it is one of the few programs where mothers can keep their children with them.
As a pediatrician, Dr. Tyler-Hill not only provides healthcare for children but helps the mothers understand what a relationship with a doctor should be like: to expect respect, have their care managed and have high expectations of a medical system. Morehouse School of Medicine pediatric residents also provide care at the clinics, which in effect serve as training sites, says Nodvin. Feedback from the mothers suggest that they feel comfortable with a physician, many for the first time.
“Dr. Hill has been great to my son… and answered all of my questions,” says Lisa, a resident at the Mary Hall Freedom House.
During the first clinic visit, each child undergoes an initial examination, including questionnaires to determine if he or she has any unmet acute or chronic medical needs. Plans are drawn up to address long-term healthcare concerns, such as developmental issues, and referrals are made to specialists.
Lula Cullen, assistant program director for Healthcare Without Walls who lives at Mary Hall Freedom House in Sandy Springs, serves as the onsite coordinator between the mothers and Dr. Tyler-Hill so that any immediate needs can be addressed. For example, one evening during the middle of the flu season, Dr. Tyler-Hill, who lives in the area, added an unscheduled clinic to examine seven children, saving them all a trip to the emergency room.
A key to ongoing success is maternal health literacy training. To ensure mothers become more proficient in healthcare, Childkind social workers Joe Sarra and Christina Mahoney provide a curriculum that focuses on access to medical services, good prenatal care, nutritional issues, healthcare for infants, toddlers and children, and that helps differentiate between illnesses that do and do not require emergency care.
To date, Healthcare Without Walls has served approximately 100 mothers and 130 children, which has included helping them secure Medicaid insurance. The majority of women reside at the Mary Hall Freedom House from six months to a year. Once they leave, however, their children can continue to be seen at the Healthcare Without Walls clinics.
Laurie Gaydos, Ph.D., assistant professor of health policy and management at the Rollins School of Public Health, is using formal questionnaires to evaluate the effect the supportive services provided by Healthcare Without Walls has on the women. A future goal is to develop a permanent community-based clinic continuing the theme of A Medical Home for Homeless Children to provide continuous, coordinated care. Hall urges professionals to leave their traditional settings to bring services to those who need them.
The ISDD is a recipient of the Rollins School of Public Health 2013 Martin Luther King Jr. Community Service Award and, in October 2012, Dr. Rubin received the American Academy of Pediatrics Calvin C. J. Sia, M.D., Community Pediatrics Medical Home Leadership & Advocacy Award.
Founded by Dr. Rubin in 2004, ISDD’s mission is to promote health equity among children living in social and economic disadvantage with or at risk for disability. In addition to Healthcare Without Walls, ISDD is home to Project GRANDD, a program that provides a network of support to grandparents in the greater metropolitan Atlanta who are raising grandchildren who have disabilities, chronic illness and behavior or learning difficulties. ISDD also has an annual program called Break the Cycle, which invites university students to develop projects that will break the cycle of disadvantage and disability and help children who live in an environment of social and economic disadvantage to lead healthier and more productive lives.
For more information, visit Healthcare Without Walls
Debra Hughes, MS, is a medical journalist, writer, and editor. She is a partner in D.A. Hughes & Associates, a medical communications company.
Yasmin Tyler-Hill, M.D., FAAP, is the Interim Chair of the Department of Pediatrics in the MSM Department of Pediatrics and on staff at Children’s Healthcare of Atlanta at Hughes Spalding Children’s Hospital. Dr. Tyler-Hill serves as Clinical Physician with Healthcare Without Walls and is a Board Member of Innovative Solutions for Disadvantage and Disability.