Modelling the children’s hospital and healthcare delivery system for the next century

Dr Benjamin Van Voorhees from the Department of Paediatrics, University of Illinois at Chicago college of Medicine talks about the provision of children’s healthcare…

The Children’s Hospital of the University of Illinois Hospital and Health Sciences (UIH) system in Chicago is at the forefront of the dramatic changes taking place in the provision of healthcare.  The era of routine hospitalisation for the treatment of many diseases or injuries is now being replaced by extensive outpatient and same-day services, and an emphasis on ensuring the patient has a regular primary care provider.

For most of the 20th Century, the prevailing view was that medicine was responsible only for the clinical issues a patient presented, and not for the constellation of other non-medical factors that impact health.  21st Century mandates to decrease healthcare costs by reducing preventable hospitalisations and primary care sensitive emergency room visits are leading both providers and payers to a recognition that medicine must take account of the social and economic circumstances of the patient in order to facilitate successful health outcomes and minimise preventable high cost interventions. These changes in the health system are needing both providers and hospitals to take a much broader view of their role in the patient’s life.

The origin of the modern hospital has its roots in the charitable activities of those who sought to provide aid to the poor, sick, and disabled.  For many children, the saving grace of hospitalisation was the opportunity to eat regular meals and, later as germ theory advanced, live in a clean environment.  The UIH system has its origins in the need to educate physicians, pharmacists, and other clinicians.  In 1881the College of Physicians and Surgeons (P&S) of Chicago was established, becoming the University Of Illinois College Of Medicine in 1913.  In 1917, the university worked with the Illinois Department of Public Welfare to establish the Research and Educational Hospital as a teaching facility.  In 1980 the current University Hospital was built and in 2011 the Children’s Hospital was opened.  It includes a 101-bed paediatric hospital, which provides general and paediatric subspecialty care to children from throughout the state.

Its primary catchment area includes some of the poorest communities in Chicago.  The primarily African-American and Latino residents are beset with a multitude of challenges, including substandard housing, lack of jobs, low educational status, and high levels of violence and criminal activity in their neighbourhoods.  These challenges interfere with a family’s ability to focus on the mental and physical health of their children, leading to vulnerabilities (e.g. legal issues, racism) and adverse events (stressors such as “daily hassles”), that must be considered in treatment and prevention programs for both children and adults.

Disparities in health status result from ongoing interactions across the health care environment, health care organizations, community and provider characteristics, and person level factors throughout the course of a child’s development.  These complex interactions, also known as the social determinants of health, affect a child’s health status, as well as his life outcomes. These ecological influences have an impact through multiple processes across time. An example might include a parent-child interaction that does not provide sufficient structure and discipline to prevent the development of oppositional behaviour. This behaviour then negatively affects the child’s development and progress at the community school level.  Poor educational outcomes often mean poor employment opportunities in adulthood.  In short, child health models must include sufficient social force (forward moving impetus) to positively impact multiple processes of disparities development over time.

The child should be conceptualised as developing across time within an ecological framework that includes the individual, family, school/peers and community. Each individual’s life course moves through a physical and social space. This space can be construed as concentric layers of family, friends/intimates (e.g. close relationships), school/work, community and wider social systems.  Social support can be derived from any one of these layers, but may be most effectively obtained from relationships that are most proximal in social space to the individual.  However, the outer rings of community and systems provide many key social influences that determine behaviour and health outcomes. For example, the lack of availability of fresh foods in low income neighbourhoods may constrain healthy eating choices. Other forms of community influence include norm setting, peer pressure and peer group comparisons, all of which affect health and other behaviours.

A medical neighbourhood needs to be constructed around each child such that the balance of protective and vulnerability factors can be optimised to minimise illness and optimise development. To function in this “optimisation role’ the medical neighbourhood must:

(1) Effectively link to social and mental health services;

(2) Use an integrated referral and tracking data base;

(3)  Co-locate social and mental health services or make them otherwise convenient to patients;

(4)  Establish the primary care clinic as the backbone of neighbourhood- based services and link it to services in the neighbourhood;

(5)  integrate community health workers into the health care team, building on their role of enhancing a family’s ability to navigate to care and developmental and social service opportunities, and;

(6) Take advantage of technological innovations that can provide low cost behavioural health interventions and supportive patient contacts.

The concept of a children’s hospital must be broadened to address the morbidity of children in adversity – mental health, oral disease, obesity, asthma, and sickle cell, consequences of prematurity, developmental disabilities – in the context of where they live and learn.

The goal of the children’s hospital must be to focus on diseases and conditions that directly affect educational progress, work force participation, relationship formation and civic/moral development. We suggest a particular focus on oral disease and mental disorders because they share common risk factors with each other and other common chronic diseases, are widespread with high morbidity, commonly interfere with management of chronic diseases, and also because treatment for these conditions is often unavailable to socially disadvantaged groups.  We are developing a neighbourhood delivery model that focuses on modifying the social determinants of health in order to promote the health and well-being of both the child and the family.

In summary, in order to address the morbidities that most profoundly affect children living in adversity, we need a new model for the delivery of health care services and of the role of the children’s hospital. This fully integrated model disrupts the progression of disease and adverse outcomes using a comprehensive model that includes mental, developmental, oral and physical diseases.  It includes a medical neighbourhood linked with electronic data bases to track outcomes, innovative behaviour change technology, and community health workers linked through advanced data warehouses and portals that allow them to track patient contacts and predict future needs.  It is a model that facilitates the successful development of the child so as to promote health and wellbeing across the life span. The Children’s Hospital at the University of Illinois in Chicago is modelling these future solutions for the problems of today.

Dr Benjamin Van Voorhees

Department of Paediatrics

University of Illinois at Chicago college of Medicine

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