Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Social Determinants of Health Through a Trauma Informed Care Lens/Grand Rounds Episode for free MOC Credit!

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Social Determinants of Health Through a Trauma Informed Care Lens/Grand Rounds Episode for free MOC Credit! · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
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I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
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In this podcast, we explore how we can provide the best, most cutting-edge,
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compassionate care for children.
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We hope to give you a unique and behind-the-scenes edge from our expert guests.
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After listening, click on the link on this podcast for free credit that may
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include CME, MOC, or ethics credit, depending on the topic or podcast.
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All right, good morning, everyone, and welcome to Pediatric Grand Rounds.
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This morning, I'm very excited to welcome Mary Garr as our speaker.
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Since 2018, retired Colonel Mary Garr has been the president and CEO of the
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Family Service, a San Antonio nonprofit started in 1903, which works with individuals,
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families, and communities to address the social determinants of health through
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a trauma-informed care lens.
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And that's what she's going to be speaking with us about this morning.
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She's a graduate of Georgetown University with a Bachelor of Science in Foreign
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Studies and obtained her master's degree in health administration from Baylor
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University and strategic studies from the U.S. Army War College.
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She's an experienced leader with decades of diverse roles and served several
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industries, including health care, city management, nonprofits,
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and the military as a CEO and a COO.
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Notably, she served as the last garrison commander of Fort Sam Houston and Camp
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Bullis during the merger into Joint Base San Antonio, and she stood up the San
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Antonio military health system as its first chief operating officer.
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She has been the recipient of numerous awards and decorations,
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both throughout her military career and through her work with family service.
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So join me in welcoming Mary this morning, and I'll hand it over to her for her grand rounds.
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Dr. Hansen, thank you so very much, and thank you for inviting me to speak today.
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I had the privilege of speaking with some of your residents earlier this summer,
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and I'm glad to talk to a larger group, including some of the faculty.
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Appreciate all of your interest in the importance of understanding the impact
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of what's going on in your patients' lives outside your specific health care
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that is being provided to them.
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As you can imagine, a lot of what we work with is what's going on in people's
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lives at home, at work, school, and in the community. And that's what we'll talk about today.
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I'll go ahead and get started now.
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First off, as Dr. Hansen said, I am at family service.
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As of January, we'll be 122 years old.
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Our mission is all about working with individuals who are struggling with barriers
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and challenges in their lives, helping them to overcome them,
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and thus ultimately strengthening their own health, that of their families and
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that of their communities.
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How we do that is by addressing social determinants of health,
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and we have also been trauma-informed in our work for over a decade.
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Before I get into some of the rest, I'd like to give some level setting on some
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definitions so we all understand that what we're talking about in the same way.
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First off, we look at the world health definition of health,
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talking about it being much more than just understanding physical and mental
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health, and then looking at the impacts of downstream versus upstream health.
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Downstream is what we are all working with, whether it's already happened in
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people's lives. I have a couple of examples here.
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Upstream is what can we do today to help prevent or mitigate changes going forward
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that could adversely affect people's
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lives here, and that ultimately could lead to good or bad outcomes.
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Just to help give you some context here about the impact of health disparities
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and how we've gotten to some of this, you may or may not know that in the United
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States, health care is the largest industry.
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We pay more in health care than all other countries in the world,
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significantly more than most.
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Unfortunately, though, we do spend the least in what's called social services.
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That includes some of the lists that I have here compared to our peer,
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you know, top 10 developed nations.
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We spend more on health care, but unfortunately, that doesn't translate into
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being top tier in health status.
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We have the lowest life expectancies, highest chronic disease burdens, highest suicide rates.
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Also understanding the highest number of hospitalizations from preventable causes,
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as well as the highest number of avoidable deaths.
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We also, in some of the stats, show that out of almost 40 OECD countries,
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we've ranked 25th in maternal mortality, 26th in life expectancy.
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And 28th in low birth weight.
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When we look at how we're spending our funds in the United States,
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for every dollar that we spend on health care, we are spending only about 90
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cents in those social services or that upstream health and how to prevent adverse
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health issues down the road.
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In our peer countries, those that have much higher health status than we do,
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for every dollar they are spending on direct health care services,
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they're spending approximately two dollars on those social services or that
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upstream health space here.
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And when we look at different comparisons as well, if you are familiar with the work of Dr.
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Elizabeth Bradley, she wrote the American Healthcare Paradox.
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She had noted in some research out there, you know, that we are spending with
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all these disparities, work also with Dr.
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Moran at the Leadership Institute of Global Health.
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He gave some examples. This was before the pandemic, but I am sure that the
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comparisons still approximately hold true.
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He noted that for one emergency department visit could be equal the cost of
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approximately one month's rent or even more at this point.
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Two hospitalizations could equal the cost of one year of childcare.
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20 MRIs could equal the cost of one social worker for one year.
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And 60 echocardiograms were the equivalent of one public school teacher's pay
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for a year. This is on average here.
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So we're seeing some real mismatches on upstream versus downstream health at
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this point in time. So where does...
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Our money go, what goes into health, and then how do we spend the funds that we have on this?
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So in 2019, our GDP, we spent $3.5 trillion on healthcare, direct healthcare.
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2021, it was during the pandemic, but it had raised to $4.1 trillion.
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When I first went into healthcare three decades ago, there were concerns that
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we were spending approximately 12% of our GDP and it was going up at that time.
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Now it is approaching 20%. And we realized that, you know, this is just unsustainable,
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you know, over time because we see an aging population in the United States.
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We're seeing more chronic health conditions at younger ages.
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A lot of them tied to issues that could be preventable.
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A lot of them tied back to the impact of social determinants of health challenges
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and barriers, and the impact of childhood trauma that carries on into affecting health as adults.
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So when you look at this slide, this shows, the research shows,
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and there's different studies out there, but most of what goes into our health
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is not tied to genetics or healthcare access.
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And I give some examples here. But when we look at how we spend on healthcare.
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About 90%, 97% is spent on our healthcare services. And here's a breakout of that.
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And then less than 3% on public health.
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This is not including those community-based orgs that struggle with grants all
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the time, but impact health in a lot of direct ways outside the healthcare system.
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So what really goes into influencing health? In the United States,
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the average person sees a healthcare provider approximately four times a year.
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That's about 15-minute appointments, 20 or 30, depending on the type of appointment.
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So we're only able to see a patient 100 minutes a year, much as we would like to.
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It is very hard to influence health because health happens where we spend our time.
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So when you're thinking about that, health happens in the home.
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It happens in the work setting for children or even adults.
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It happens in school and then in after school programs.
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Other huge influences of health are, you know, can we access grocery stores,
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you know, whether it's H-E-B or Walmart, even Dollar General, et cetera.
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So, you know, do people have transportation to get to the grocery store?
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Do they have nutritional literacy to know what is involved with healthy eating
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for themselves and their families?
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Do they feel they can afford healthy foods? Are they ending up going to the
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Dollar General store because they don't think they can afford fresh fruits and vegetables?
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So they're spending less money, but they're buying highly processed foods that are not nutritious.
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And as you well know, we have people who are obese who are also malnourished
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and people who are very thin, but also not healthy either.
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So other big influences are on health. Do people have access to safe outdoor spaces? Okay.
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We know that's important, not just for physical health, but also mental and
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emotional health as well.
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And if you're living in a neighborhood where you don't have parks nearby or
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sidewalks, or as you know, in San Antonio,
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the impact of stray dogs in the neighborhoods or the impact of gangs,
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you know, our drive-bys, or if you know where the local meth house is in your
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neighborhood and you don't know your neighbors, you know, even to help you support
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you if you need to, you know, borrow something or need somebody to help look
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out for your children, et cetera.
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And I'm talking about the neighborhood around our community center that Dr.
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Hansen has been to, but we have many neighborhoods like that here in San Antonio.
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And then do people have access to culturally, educationally enriching learning
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spaces outside of school or such as libraries, museums, et cetera,
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or do they feel that they're on part of town that they don't have transportation
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to, that they're not comfortable with going to, they don't feel they would be
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welcome because it's for the affluent people, not for them, et cetera.
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And then the impact of faith-based organizations, churches, synagogues, temples, et cetera.
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Those are trusted agents for so many people.
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And those are places that people will go to when they have questions and ask for help.
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So do we bring the faith-based community into helping folks understand what
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goes into health and how they can be healthier?
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And then, of course, community organizations who are very deeply rooted,
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many of them grassroots in the neighborhoods that they serve,
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how can you leverage and access them to help work to improve health outside of your own practices?
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So when we think about this, we need to rethink health and think about what
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is truly included in that spectrum of health and who is involved in it.
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And that really involves that downstream, upstream collaboration.
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Because when we think about it, social determinants of health,
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those impacts start before we are born and go through every stage of life up
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until, you know, the very end.
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And we also have to realize that they are often intergenerational,
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that, you know, what is happening today was affecting the parents and the grandparents
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and the great-grandparents before them.
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And then realizing too that social determinants of health affects our entire population.
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And so we've got to look at it from that lens as well.
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And generally when I'm able to do this in person, I'll go into more detail.
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But when we think about types of health, it's not just physical,
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mental, emotional health, but it also includes things like social health,
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financial health, environmental,
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occupational, spiritual health, and then thinking about health of individuals,
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families, and communities because they all intertwine.
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The impact of an individual's health within the family can affect the entire family's health.
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And that family's health can affect the neighborhood and the community.
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And if a neighborhood is struggling and suffering, that definitely impacts the
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families living in it, which impacts the individual. So everything is intertwined here.
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So understanding that there are multiple definitions and models tied to social terms of health,
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the one that we subscribe to and follow at Family Service and we talk about
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in the work we do here in the communities and try to promote is a national,
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you know, federal model through the Department of Health and Human Services called Healthy People.
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They've been around since 1979.
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They bring together health and healthcare experts every couple of years and
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then every 10 years, they give an update,
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this time Healthy People 2030, on things that go into their mission about how
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to promote, strengthen, and evaluate our nation's efforts to improve health
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and well-being of all people.
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Here are some overarching goals tied to that. Again, things that definitely
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all communities want to be subscribing to.
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And what is nice about Healthy People, it is a national model so people can
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compare community to community.
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There's programs, there's indicators right now over 350 tied to it that communities
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can look at scaling at the local level.
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And then, you know, from there saying, what do you think is applied to local
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areas? We know things like diabetes and.
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Obesity, heart disease, et cetera. Things that we're even seeing at younger
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ages that you will be seeing if you haven't already, even in some of your children,
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higher prevalence now type two, not just type one diabetes.
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And we have too many families that think that it's just tied to genetics and
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that their child has it because they have it and their grandparents had it,
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et cetera. Therefore, it'll just continue.
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When we know and the research is showing that There are preventable ways to
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address diabetes, to prevent people from getting it, and even to do a little
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bit of reverse, or people are diagnosed as pre-diabetic on how to start.
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Preventing them from falling further into that and becoming full diabetic.
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And that's just one example. But that is a program that you all could look at
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if interested to see what could be affecting your patients and how to be engaged in it.
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But these are the overarching goals here. The one at the bottom is where a number
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of us are working locally trying to build bigger awareness of social determinants
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of health and how can we work better together across sectors and not just think
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of it as a health care problem,
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but really as a problem for all of us that are touching health to be working together on.
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So in this model here with healthy people, this definition,
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you know, here is what they use and those, they're looking at social determinants
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of health being those conditions and environments where people are born,
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raised, live, work, play, and age that can affect their long-term health outcomes,
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their life potential, their quality of life.
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It really presents opportunities for people to be happy, healthy,
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and successful, or it It puts barriers in their way to be able to,
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you know, to prevent them from being able to do so.
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These items listed on this slide, I can tell you are things that we see specifically
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in our organization with the clients and families that we serve. A number of our peers do.
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I'm sure you either are or will be seeing this with a number of your patients as well.
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And oftentimes these are tied back to social determinants of health and also
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to the impact of adverse childhood experiences or childhood trauma,
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which is also for many a part of SDOH, but not for everybody.
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So in this model, they have five different major domains, economic stability,
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having access to high quality education all the way from early childhood to adult learning,
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having access to healthcare and understanding health in that context,
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having a strong neighborhood and built environment or infrastructure to support,
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and then also having strong social and community context or engagement.
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And I'm gonna go into more detail for that in just a moment here.
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Here's some examples within those five areas, obviously economic stability,
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everything from being in poverty to food insecurity, housing instability, et cetera.
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And then if you don't have strong educational supports from early childhood
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all the way up to graduating from high school and going on to college, career,
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job training, it is hard to then have good job skills or access to careers,
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which then ties back to economic stability.
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The healthcare piece is primary care, also health literacy, nutritional literacy,
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and having the language to be able to articulate that and understand it and process it.
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The neighborhood and built environment, it's having access to those supports,
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having safe homes, safe neighborhoods, etc.
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And on that social community context, this gives some examples,
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but I think of it more in terms of do people know how to access resources when they need them?
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And do they also feel that they are able to contribute to their neighborhoods,
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to their communities, so they can
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have that sense of purpose and not feel isolated, alienated, and alone.
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So with that, to be able to understand where we're at today,
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we really also have to understand our past.
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And so when we think about our past, there are two major factors tied to that.
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One is institutional bias, which really has worked systematically to give certain
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groups advantages over other groups.
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And I give examples here of what has been involved with that in the past.
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But when you look at that and you think about, for instance,
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the impact of slavery and how that still carries over today,
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or land displacement with Native Americans and then their children being put
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into boarding schools and forced to not be able to use their native language or learn their culture,
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et cetera, and the impact on so many of our Native Americans today.
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And then you think about the bias towards certain religions,
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if you're familiar with red lighting,
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you know, and that it was up until just recent decades, and this was at federal,
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state, and local levels, that depending on the color of your skin,
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your race, and ethnic background,
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the deeds were being written to say that people of certain colors could live
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in certain neighborhoods.
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But if you were another color, you could only live in other parts of town.
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And banks would not give mortgages to you and it would be specifically written into the deeds.
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And if somebody in a home tried to sell that home to somebody of a different
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race, they would not be allowed to do so.
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And when you think about our biggest asset and our lives for most people is
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home ownership and being able to transfer the wealth of our home to our children or grandchildren.
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And when you're thinking about affluent homes that were built 80,
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100 years ago and passed on or then sold, those homes back in the day might
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have started, and I'll use San Antonio, let's say in Alamo Heights.
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About $6,000 to $10,000 to be built back then.
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And many of those homes today are worth a million or more dollars.
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Other parts of town, such as on the west side and the south side,
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the homes might have cost three to five thousand dollars to build, you know, decades ago.
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But even today, because of where they're at, those homes now are valued,
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you know, a hundred to two hundred thousand dollars.
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So not as much wealth has been built. And with the cost of home ownership and
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maintenance, it's also been hard for many of them to maintain their homes.
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And for many of those folks today, they receive code violations,
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they struggle with property title clearances, and they're at risk.
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And a lot of them have had homes taken away from them. They've been evicted.
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Homes have been demolished because they've not been able to maintain those homes.
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So, again, a lost opportunity there in being able to pass on.
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And when you also think about a further effect of this downstream,
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when you're tying it into education, as you know, in Texas, as in many states,
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our school system, our public schools specifically,
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are primarily funded through property taxes.
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And if you have a million-dollar home and property tax for that versus a $100,000
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home and the property tax for that, then it's much harder to have the funds
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available to support those public schools.
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And there's a lot more in-depth on that, but that just gives you a taste of
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the challenges that we all have experienced.
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In terms of being able to have an equitable balance here for building wealth,
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for being able to fund education, which ties to future job opportunities, et cetera.
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Now, under systemic barriers in our past, that's where people can be unfairly
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discriminated against and not be able to fully participate in society or in community, et cetera.
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And here's some examples here. The digital divide specifically is where people
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have not had access to technology,
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to Wi-Fi, to broadband, et cetera, to be able to help them do their work,
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do school, do learning, et cetera.
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And if you think about it in comparison to back in the 1930s,
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when President Franklin Roosevelt said that it was no longer a luxury to have
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electricity, it really was a necessity.
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And they had the electrification program across our country,
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especially in rural areas.
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Today, we're at that same point with access to our digital world.
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It is not a luxury anymore. but we
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still have many areas a lot of them in our rural areas but
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even here in our urban areas where people don't
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have consistent access they either can't afford it
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or that wi-fi has not made it to their their home or their neighborhood we still
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have had that in san antonio we saw that clearly during the pandemic when there
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are many students that did not have access at home and schools were having to
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have hot spots in their buses in the parking lots for parents to take kids,
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if the parents were able to take their kids to go learn, and then they didn't have.
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Computers or tablets at home.
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At schools, a lot of them would issue tablets, but maybe it'd be one per family
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in some of our poorest school districts.
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So a lot of gaps there. That's one example.
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I'll talk about the school to prison pipeline more in a minute. Healthcare access.
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In the United States, over 60% of our healthcare access is tied to employer insurance.
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But if you don't have insurance, you know, then it is much harder to access
22:54
health care. And it could be self-pay or could end up being compensated care.
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For many people, the emergency room ends up becoming their primary care site.
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And they're coming in at a later point than when they should have.
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They're not getting preventive care or wellness checks.
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And then when they come in, they are sicker and harder to treat.
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It's more expensive, sometimes already terminal. We've seen that before.
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And so, you know, that is a challenge here. But even in hiring and promotion practices,
23:20
and we all know that should be fair and equitable, but even with how they work
23:26
to screen, if somebody's name stands out or if a race stands out,
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an ethnic group stands out, or a gender stands out, that could overtly or covertly
23:38
be a reason to not hire or promote somebody.
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Transportation is a huge barrier. You may have patients that struggle to be
23:47
able to get to your appointments because they don't have sufficient transportation.
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And even if they rely on our bus system, which we know is not very adequate
23:55
here, we don't have strong public transportation here. It might take them an
23:59
hour or more to get to your appointments because they're having to change buses in two or three times.
24:04
And if they don't have access to affordable child care, what are they going
24:08
to do with their other children when they come to your appointment?
24:11
You know, or is that going to prevent people from working because they don't
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have access to safe, affordable child care?
24:17
And unfortunately, as you may or may know at this point, when we're looking
24:22
at the impact of child abuse, unfortunately, there are too many kids that are
24:27
actually abused by other children.
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Family members or caregivers who are watching the children because that's all
24:34
that that parent can afford.
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And they thought that they were safe, but then the children weren't.
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And we see that with some of our counseling, unfortunately, and you might be seeing that as well.
24:44
And then language culture. And I talked about the wealth aspects there already.
24:48
But that all ties to our past, which is now affecting where we are at today.
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And this is that same slide that I showed earlier.
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This is what we deal with today, good or bad.
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The future is where we would like to see.
25:03
Having opportunities to be able to have consistent, healthy food,
25:07
access to affordable housing, being able to build wealth, good job training
25:11
because we've had strong education supports.
25:14
Having that access to healthcare, both physical and mental health,
25:18
having strong health literacy.
25:20
And then again, I talked about social and community context.
25:23
And And, you know, and that's across the board. And the second chance or program is,
25:28
you know, for those who've been formally incarcerated and do they have an opportunity
25:32
after they've paid their dues
25:34
or debt to be able to be rehabilitated and reintegrated back into society.
25:38
And then that neighborhood and built environment, I give some examples here,
25:42
everything from being in safe homes to safe neighborhoods.
25:46
And if you think about the safe homes, you know, we have too many.
25:50
Especially the older housing stock where children are at risk with lead paint.
25:55
We know about Flint, Michigan with lead pipes and the effects in the water,
25:59
but that's not unique to them.
26:00
We see that around our country, especially with the older infrastructure,
26:03
so many cities around our country, asbestos, other challenges within the home setting.
26:10
And if they are in older homes and struggle, let's say with pest control,
26:14
then we know the impact on the
26:16
respiratory system with all of that if they don't have air conditioning.
26:20
And I can tell you that the Department of Labor requires all public housing
26:25
to have heating, but what they don't require in our public housing is air conditioning.
26:32
And when you think about being in South Texas and the impact of not having air
26:37
conditioning in the heat, we know that effects are most vulnerable,
26:41
which includes our older adults, those who are immune compromised,
26:44
and then our young children as well.
26:45
That can also compromise respiratory systems, aggravate, you know,
26:50
asthma, COPD, et cetera here.
26:53
And then, you know, within the neighborhoods, as I mentioned some examples earlier,
26:57
is do they have the supports and the infrastructure in place to be able to safely
27:02
live in those neighborhoods here?
27:05
So on the national landscape with SDOH, I wanted to show you this CDC slide,
27:09
Centers for Disease Control.
27:11
And this talks about, you know, at the bottom of pyramid, this is where we would
27:15
like to see having the biggest impact for the largest number of people.
27:19
And here's some examples of ways that, you know, working upstream,
27:24
you know, improving long-term health outcomes, having access to early childhood
27:29
education, having access to public transportation to be able to move around.
27:33
If you live in poverty and don't have good transportation or supports,
27:38
your world is very, very small. You don't really get out of your neighborhood.
27:42
A lot of the people we work have deep-rooted poverty and they don't get out.
27:47
So we go to them to be able to meet their needs.
27:50
And then, you know, ways to help people live safely in homes and access home ownership.
27:55
Earned income tax credit, if you're not familiar with that, that's something
27:59
the federal government set up decades ago so that families who otherwise might
28:05
not have filed taxes, but they're eligible for child care, child tax credits,
28:09
they through the VITA program, volunteer income tax assistant program,
28:13
or on their own can file taxes and receive a credit.
28:16
And they're from there receive a refund, even if they didn't think they were
28:20
eligible for our needing to file taxes.
28:23
And then obviously fluoridation of water. We know the impact of dental health
28:26
on physical health as well. Well.
28:28
San Antonio was the last large city to actually fluoridate its water.
28:32
People thought that it was a toxin and that would affect the quality of the
28:38
water and the taste of the water, and they didn't want it.
28:40
And we know that fluoride for children and adults as well helps to have strong,
28:46
healthy teeth. But those are just some examples there.
28:49
And then the next level up is how can we make the default choice the right choice?
28:54
So for instance, it was only 15 years ago that here in San Antonio that we actually
29:01
said we don't want smoking in public buildings and then restaurants,
29:05
et cetera. So that ordinance finally passed.
29:08
Before that, you go into a restaurant and say, I would like to sit in the non-smoking
29:13
section, but two tables over was the smoking section. So it really wasn't non-smoking.
29:18
So, you know, how can we make that, you know, the right choice,
29:21
the default choice, you know, seatbelts and cars have saved countless lives
29:25
at this point in time, but that used to not be a mandate here.
29:29
And then here's a few examples as well on that.
29:33
And then moving up that pyramid, that's where we tend to focus a lot more is
29:37
one-on-one interventions, which are very beneficial and helpful,
29:41
but that's where we put a lot of the resources and we need to be able to help
29:44
bring that down to the lower end of that pyramid here.
29:47
So here's some examples of community efforts.
29:51
These are national programs and grants. Some of these are ones that are being done here,
29:55
either through San Antonio's MetroHealth or other orgs, but these are available
30:00
throughout the country, and they tie to different effects of impacting SCOH
30:05
that affect physical health down the road.
30:08
I wanted to spend more time here on helping to go more in depth of giving you
30:12
some context from both upstream and downstream health.
30:15
I don't have time to go into a lot of detail, but I just want to give you a
30:19
basic understanding and you can feel free to go look up more on your own.
30:24
These are not all inclusive, but it just gives you an idea of what we're talking
30:27
about across these five domains.
30:30
And also realize that if something is going on in one area with an individual
30:35
or family's life, then generally speaking, there's more things going on.
30:39
And what I talk about is we'll have folks coming in to our emergency pantry,
30:43
for instance, and ask for help with diapers, which are expensive,
30:47
or hygiene supplies, school supplies, et cetera.
30:50
Well, you know, we provide that, but then we start working with them on the root causes as well.
30:55
Why do you need these supplies? And what can we help you to do so you can be
30:59
at a point where you can afford that for yourself and your family.
31:02
And then they all tie to these root causes here.
31:05
Surrender economic stability, what we would like to ensure is that people have
31:09
access and can support themselves with affordable, healthy food.
31:14
Access to job training, you know, housing that they can, you know,
31:18
afford here and not be at risk of being evicted or foreclosed on.
31:22
And then being able to understand, you know, their financial status.
31:26
We work with folks that they don't know and understand their debt.
31:29
They don't know what a credit score is. And as you know, in today's world, we need credit scores,
31:34
you know, to be able to not just get a home loan or a car loan,
31:37
but also, you know, to get into an apartment, you
31:41
know and employers look at it so that is a very critical piece
31:44
for now and so you know then helping people to get
31:47
out of predatory lending or payday loans
31:50
or predatory banking we've seen this time and time again we'll
31:54
have people come in that took out a four hundred dollar loan and now you know
31:59
two years later they owe two thousand dollars on it because of the the type
32:03
of loan that it was and where it was from and then how do people work to build
32:06
assets and then being able to have ability to grow and, you know,
32:11
opportunity for job skills and training or college, etc., which ties into the next one.
32:16
We need to ensure that, you know, children have that early education and that
32:21
high quality education to be prepared for kindergarten.
32:24
Research shows that a child that is ready for kindergarten when they start kindergarten
32:28
is more likely to be reading at third grade level than third grade.
32:32
And up until that time, as you know, children are learning to read.
32:36
But from third grade on, they are reading to learn.
32:40
And if they didn't learn to read or read very well, then they are going to be
32:44
struggling in that foundational area.
32:46
And if they don't receive extra supports to help them move forward,
32:49
they're at risk of falling through the cracks and being pushed along or becoming
32:54
disenfranchised or uncomfortable or getting in trouble, et cetera, and dropping out.
32:59
And if they do that and don't graduate, then it's harder for them to go on to college and career.
33:04
So it's having all those supports. But even then, if people are going on to
33:08
college, and we see this with a lot of first-generation college students,
33:12
especially if they aren't.
33:14
Going local. We do a lot of great work to help kids get scholarships to go up.
33:18
Then do they have the supports to stay in college?
33:20
Financial is a key one, but it's also all those other emotional supports and
33:25
cultural supports when this is so different and new to them because they've
33:29
never had a family member go to college before.
33:32
And then ensuring that they graduate and are ready to move on to that first
33:36
employment and start building out a career.
33:39
The healthcare piece, Again, the mental health access, we saw this before the pandemic.
33:44
Many folks now have realized how much mental health supports are needed for
33:49
our children, our schools, but really all phases of life, even older adults.
33:53
And then addressing the impact of childhood trauma. I'll talk more about that.
33:57
Accessing affordable health care and then that literacy piece.
34:00
Under neighborhood and built environment, making sure we've got safe neighborhoods,
34:05
safe homes for our families here.
34:07
Improving our zoning codes and compliance of those. Again, I can use the stray dogs as an example.
34:13
Many of them actually aren't, they're aren't feral.
34:16
They are owned by people that either can't maintain their fences and yards or
34:21
don't pay attention and just don't understand that or don't care.
34:25
And then having those safe outdoor spaces, as I mentioned, how important that
34:29
is for physical and mental, emotional health.
34:32
Understanding our first responders. You know, we work with a lot of folks that
34:36
didn't have supports from authority figures, whether it was police,
34:41
fire, you know, even health care, schools, et cetera, government.
34:45
And it's helping them be comfortable and understanding those supports and building
34:50
those relationships so that police know their communities that they're supporting.
34:54
And for instance, you know, we finally incorporated a mental health response
34:58
team embedded in our police response so that if a mental health crisis is going on,
35:04
it doesn't escalate into loss
35:06
of life or something that could have been prevented because the police,
35:10
who aren't mental health providers and shouldn't have to be,
35:13
but they understand and bring in the right folks to help through that de-escalation here.
35:17
I mentioned the digital inclusion piece, making sure we're eliminating food deserts.
35:22
We still have areas where they don't have good access to food or transportation for that.
35:27
And then that social community context, again, the second chance opportunities,
35:31
but having community resources available for individuals and families,
35:35
making sure they understand they're out there and how can they be engaged.
35:38
And decreasing isolation of older adults, also very critical.
35:43
And we saw that also during the pandemic where that cognitive decline was happening
35:47
so rapidly for them. But we see that with folks at all ages.
35:51
The downstream is the flip side of it. People who can't afford the rent or mortgage.
35:56
2019, Bexar County, this is before the pandemic, evicted 13,000 families,
36:02
not individuals, but families that included children.
36:04
Imagine that trauma of seeing all of your worldly possessions being put out
36:09
on the front lawn and you've been kicked out and a lot put on your home because you couldn't afford it.
36:14
So that, you know, stopped during the pandemic, but it has been rising again.
36:18
I don't have today's numbers, but they have pretty much gone back up to before.
36:22
That being homeless and near homeless, and we have that point in time,
36:26
count every year on homeless, but that doesn't include folks that they don't
36:30
see living in their cars or that are couch surfing, or that we have multiple
36:34
families sharing homes together in some families, but a lot of times not related to each other,
36:39
but that's the only way they can manage at this point in time.
36:42
Too many people are unemployed or underemployed, and that also means without
36:46
benefits, so generally without health insurance, without paid time off.
36:51
So if they get sick or need to go to an appointment, they don't get paid. All of that adds up here.
36:56
Not being able to build wealth, which I talked about, is incredibly important.
37:01
Continually relying on food pantries.
37:03
We see intergenerational families relying on food pantries, relying on public housing.
37:09
And our public housing system is set up that if you now get to a point where
37:14
through job training or supports, you are able to earn a little more that could
37:18
kick you out of your public assistance, which includes your home.
37:22
So we see generations of families also living in public housing because we don't
37:27
work with them to actually create a system where they can safely and easily
37:31
transition out to manage on their own without it.
37:34
And then wanted to emphasize again back to the importance of reading.
37:39
In our prison system today in the United States.
37:42
The average reading level is below fourth grade.
37:46
And I talked about the importance of third grade reading level being a key support
37:51
to help people thrive and succeed to graduate from high school and beyond.
37:55
And so when you compare that then to those who are in prison,
38:00
many of those, you know, one have been victims of abuse themselves growing up.
38:04
Two cannot read and cannot function, had dropped out of school,
38:08
don't have other means to support themselves.
38:10
And we have what we call the school to prison pipeline where we are investing
38:14
in our prison system, which we pay more per day in the United States for people
38:19
in prison than we do per day for a child in our public school system.
38:23
We are investing after the fact rather than investing up front to help these
38:28
child succeed and thrive in school.
38:30
And over 85 percent of our low income families and particularly children of
38:36
color are in our public schools, not our private schools. And so we have to
38:41
ensure that we have the right investments there up front.
38:43
And that ties into the education piece, making sure kids are not dropping out
38:48
of high school and middle school as well.
38:50
Some don't even make it to high school, which means they don't have paths to
38:54
viable careers down the road.
38:56
They don't have basic skills that they need, including critical thinking skills.
39:00
The health care, we talked about the chronic health care issues.
39:04
Seeking health care later, lack of health literacy.
39:07
And then on that mental health side, when you look at that, a lot of times we
39:11
have people in our prisons that have mental health issues or substance abuse
39:15
issues that have led to mental health issues, childhood trauma that have led to that as well.
39:19
And so we have that revolving door with our prisons and mental health, too.
39:23
That neighborhood environment, I gave a bunch of examples on that already.
39:27
And then the same thing with social and community context.
39:30
We know our neighborhoods that are the poorest socioeconomically.
39:34
We also know where our teen pregnancies are, where our gang activity,
39:38
where our substance abuse, where our crime rates are.
39:40
They all overlap in those same areas, which means that they are struggling communities,
39:46
a lot of toxic activities going on as opposed to what can we do to help strengthen them.
39:53
So I want to now flip the script a little bit and show this interrelationship
39:57
between social terms of health and the impact of adverse childhood experiences or childhood trauma.
40:03
And I want to emphasize that ACEs can affect anybody at any socioeconomic strata.
40:09
Absolutely. Just like domestic violence. But ACEs disproportionately affects
40:13
those at the lower end of the socioeconomic strata who are least equipped and
40:18
have the fewest access to resources to be able to deal with those.
40:21
It could have started with historical trauma.
40:23
I gave some examples in that past slide. But regardless that adverse child experience
40:29
or experiences occur, if you've been through the training, as you know,
40:32
it can cause some epigenetic rewiring of the brain.
40:35
These children are adapting to survive in that dangerous world that they're
40:38
living in that could affect their social, emotional,
40:41
cognitive functioning, could cause them later on to adopt the same health risks
40:45
and behaviors that they experienced or were exposed to, which then could cause,
40:50
you know, lead to higher risk of diseases, disabilities,
40:53
struggles to engage socially with others, and then ultimately to early death.
40:59
So with that, you know, here are examples of average childhood experiences.
41:03
We haven't had this training yet.
41:05
We see these with those that we serve, unfortunately.
41:08
And then with that, you know, ACEs can have lasting effects on health behaviors
41:13
and long-term, you know, life potential.
41:16
And a lot of times we see that, you know, where, you know, people are born and
41:20
raised has a huge effect on their lifespan.
41:23
The same thing with ACEs. There could be up to a 20-year more difference in
41:27
life expectancy, and the data clearly shows this.
41:29
This is a slide for the CDC, and they show a lot of direct correlations to specific diseases.
41:35
Brain science research, just quickly going through that, that,
41:39
you know, they're showing that the impact of toxic stress versus nurturing based
41:43
on the, you know, experiences that a child is going through and at what stage in life as a child.
41:48
And as we know, brains continue to evolve and mold through their mid-20s,
41:52
and that nature versus nurture, those environmental factors that layer into
41:57
what is going on in the developing child's brain and how that can affect how
42:01
they're going to be as an adult.
42:04
We can see a lot of this. We see this with our clients that we serve,
42:07
our children, families, adults.
42:09
You might see this with your children as well. And there's risk then of having
42:12
a diagnosis that's a mental health diagnosis when it's actually behavior health
42:17
tied back to the impact of the ACEs that they have been experiencing.
42:22
Effects of high ACEs go across the lifespan. Here's a few examples here.
42:26
But you can see it in children.
42:28
You can see it in entire families. You have cognitive functioning, being able to interact.
42:32
If you know that's happened, it's understanding, you know, the extra layering
42:36
of support and communication and how to best respond to them without re-triggering,
42:41
but being able to help them put that point in time back in the past while they're
42:46
trying to deal with what they're going through now and be able to move forward in a more positive way.
42:51
And the research shows, you know, all of these kinds of things as well.
42:55
Those with zero to three ACEs, with all else, you know, being out there,
42:59
more likely to be on the left side of the scale for a more higher risk doesn't mean they will,
43:04
but higher risk if they don't have that buffering support here and mitigation
43:09
to be ending up with these kinds of risk.
43:11
And again, we see this with the clients that we serve.
43:14
You might be seeing this with your patients too.
43:17
Responding to chronic stress when you have those higher executive functioning
43:21
skills, able to manage, you know, and self-regulate, be able to adjust your potions, et cetera.
43:27
Otherwise, you know, if you're struggling with the effects, you might be triggered pretty quickly.
43:31
You might either react in a very angry way, be able to not be able to sit still
43:35
or really disassociate at the opposite end here.
43:39
From there, it's working to build resiliency. You know, there is hope out there for it.
43:43
Early childhood to later childhood to adult learning. I don't have time to go
43:47
into a lot of that, but it gives you a few things here to think about.
43:50
And then from there, I want to go back to the SDOH because ACEs is a component of that.
43:58
But here are some tools that you can use that are out there.
44:02
The CMS ACH tool, Accountable Care Health Tool is available for you.
44:08
That is an approved tool.
44:09
The PREPARE tool, the American Academy of Family Practitioners also has a tool out there.
44:16
And there's a few others. Those are ones that can help you assess SDOH with
44:21
your own program, and I'll talk about why in a moment.
44:23
And then working with community partners that are doing the work outside of
44:27
your practice, outside of the clinic or hospital that you're in,
44:30
because they're the ones that can then follow up and work with the SDOH issues.
44:34
So I work with social services organizations or CBOs, community-based.
44:39
Most of them are deep-rooted, grass-rooted. They know the individuals,
44:43
families, and neighborhoods they serve. Many of them come from that same background as well.
44:47
They are working to address one or more SDOH barriers or challenges already.
44:52
They're experts in their fields with the work that they do.
44:55
They also work to be voices or advocates or amplify the voices of the populations
44:59
they serve, many of them who haven't been able to do that in the past.
45:03
They also tend to be very efficient in making maximum use of their funding and
45:07
at navigating multiple systems in our society and communities here.
45:11
So why do we need to code for social terms of health? One, since 2015,
45:16
they have been available.
45:17
I've given Delia a sheet that she'll give to you that talks about SCOH.
45:22
It talks about the specific codes out there. And in that, the TIN codes and
45:27
have a lot of subcodes out there, they are updated every six months.
45:30
So there's more being added that you can review and access.
45:33
But with that, you get better care coordination, better referrals and support
45:38
for your vulnerable patient populations that otherwise you wouldn't know were an issue.
45:42
So you might have a family that's living in their car, but if you don't know
45:46
that, then you don't know the impact or they don't have a refrigerator.
45:49
So they can't refrigerate their meds or they can't afford their meds.
45:53
So they're either not buying it or they're diluting it or they're struggling
45:55
to show up to appointments because of transportation issues or child care, etc.
46:00
And the list goes on. You can also have better tracking of your patient health
46:04
outcomes to see of what supports are being provided in the community for them
46:08
are now helping improve your outcomes as well.
46:11
We're doing a program with UHS, and we've been seeing clear outcomes and improvements
46:16
with the work we're doing with them, also with community first.
46:19
Also with coding, you can work on improving delayed access to items here that
46:25
I have listed here that could have either been prevented or could have been
46:28
less resource intensive.
46:30
You can also look at correlations between SDOH and high-cost claims.
46:34
You have a lot of frequent flyers who are being readmitted regularly or frequent ER visits, etc.
46:42
And then as of January of this year, healthcare systems, according to CMS,
46:46
have to have a process in place for screening for SDOH.
46:50
And some of those tools, all of those tools that I list are the ones that are
46:53
acceptable tools in doing so.
46:55
And then what do you do about it? And that's the linking out here.
46:58
This is the form that I gave to Delia that she's going to share with you as a PDF.
47:03
And with that then is, is how do you work to prevent these negative downstream effects?
47:08
One, we need to continue to establish or advocate for those policies,
47:12
laws, ordinances, regs that work to positively influence social and economic
47:16
conditions, those that support changes in individual behavior,
47:19
and thus can improve health for large numbers of people.
47:23
And very key is how we can sustain it over time.
47:26
Two, the work that we're all doing right now is what can we do to improve those
47:30
conditions where people are born, raised, lower, play, and age to really create
47:34
that healthier family, that healthier community, healthier workforce, et cetera.
47:38
What can we do to include improved collaborations? And that means the upstream,
47:42
downstream healthcare systems with education systems, with CBOs,
47:46
with government, with business, et cetera.
47:49
Making sure we're doing research to show what is working, what's not.
47:53
What can we do to improve upstream health while we're dealing with downstream
47:56
effects, and then fund appropriately to those orgs and those areas that really
48:01
show that demonstrated improvement in long-term health outcomes.
48:04
Because at the end of the day, we wanna see this, you know, children on that
48:08
top path, a lot of supports at every stage of life.
48:11
So they end up becoming strong, successful adults, breaking whatever challenges
48:16
or barriers they were born into and have a long, healthy, successful life.
48:20
The bottom one is the ones that we see too often, and then they struggle.
48:24
They aren't supported, they end up dropping out of school at some point,
48:28
not having a viable career path.
48:29
If they're alive at 40 or 50 years old, they're more often had potentially run-ins
48:35
with the law, no strong employment, strong challenges with social engagement,
48:41
a lot of health issues, and potentially continue that cycle with their own children.
48:46
And we want to see thriving communities that work together and help each other,
48:50
not toxic communities with all that comes with that.
48:53
And with that, I'm going to stop
48:55
sharing my slide now and answer any questions that you all might have.
49:00
All right. If you have questions for Mary, you can either put them in the chat
49:03
or unmute or raise your hand.
49:07
And I can tell you this was a very high level overview.
49:11
I was really trying to give you a taste of understanding a little bit about
49:16
the impact of social and social health,
49:18
the impact of adverse childhood experiences, how they interrelate,
49:22
how you may be seeing those in your patients without even realizing it,
49:27
and things that you can think about to be able to address them moving forward.
49:32
Mary, I had one question, which is so often the structural barriers you talked
49:36
about, particularly the digital divide and transportation, can make it hard
49:42
for us to make those connections to the community agencies.
49:46
And so there's also a request for you to talk a little bit about your agency.
49:50
So maybe can you talk a little bit about family service and how you guys specifically
49:54
address those barriers in connecting families from identifying the issue to
50:00
connecting them with y'all?
50:01
Absolutely. So we actually are structured on the Healthy People Framework.
50:06
So I've got over 30 programs and services across all phases of life.
50:11
So we have, I'll just go through the lifespan. We have Early Head Start and Head Start.
50:16
And then with that, it's not just for the children. We assess the whole families.
50:20
We use the CMS Accountable Care Tool in our assessment of all of our clients,
50:26
along with the ACEs, one of the ACEs tools, so we can understand those needs and barriers.
50:31
With that, we also have programs in elementary, middle, and high school to help
50:35
children who are at risk of dropping out or struggling to be able to stay in and thrive.
50:40
And then we have adult learning programs, workforce development to help with
50:44
job training, either with our own programs or linkages to the various universities.
50:49
And we work to find scholarships or funding also for other job training programs out there.
50:55
We do economic stability. We have financial counseling and coaching,
50:59
not just literacy, because we work with folks who really need one-on-one help.
51:03
They don't know what a budget is and they struggle. And I talked about some examples there.
51:07
And then, you know, with the health and healthcare, we have behavior health
51:11
counseling for children and families.
51:13
You all actually refer to some
51:15
of your residents have already been referring to us. We have programs.
51:18
We're in the Robert B. Green Clinic. We work with UHS.
51:23
We work with a lot of different entities. So we deal with all aspects of behavioral health.
51:27
We have school-based health, as well as in our own sites, telehealth.
51:32
We do home health as well for that. We have...
51:36
Supervised visitation programs for those non-custodial parents that are court-ordered have to come in.
51:42
We work with the juvenile justice kids that are referred to us through DFPS.
51:45
We work with CPS clients also.
51:48
I mean, we just have a whole host in that range here. We have an older adults
51:52
program that we do for a state license to do personal care and homemaker services
51:56
to help older adults be independent in their homes.
51:59
We've got social and community engagement opportunities. We do parent strengthening.
52:03
Parent engagement is parent strengthening because we work with a lot of very
52:07
dysfunctional families that have just struggled.
52:09
So, you know, we take for granted the idea of having dinner at home together,
52:14
playing with your kids, talking with your kids, being there for your kids.
52:17
You know, we work with parents who are just struggling or we work with foster
52:20
parents who work with grandparents, raising grandkids, et cetera.
52:24
And then we also have our community centers, you know, here we also we're in 14 counties.
52:29
So we're, we have community centers here and in Crystal City and sites in Uvalde
52:33
as well. We've been there over a quarter century.
52:35
And then we have an SCOH case management specific program.
52:40
Just trying to think. We've got Team Tech Center and we just have a multitude
52:44
of programs with the services that we provide.
52:47
And to your question about how to help people with these transportation barriers,
52:51
for us, we either go to their homes with our work. We provide bus passes.
52:57
We get discounted passes from VIA that we can give bus passes to people for them.
53:01
If we can link them with other programs with
53:05
our family strengthening programs you know we work in various schools
53:08
so we help to build networks of relationships
53:11
for families that otherwise aren't connecting so that now they can build some
53:16
self-sustainability within their own community so that now they've got a family
53:20
network of people sharing similar struggles and how can they work together and
53:23
help each other and help each other with the kids or transportation etc so those are a few ways there,
53:30
Thank you. I know you guys all do so much, and it's really amazing if anyone
53:33
has a chance to visit your neighborhood center.
53:36
That was very cool to see all the different agencies that you collaborate with.
53:40
Dr. Robinson had a similar question around transportation, which I think you
53:43
partly answered, but just systemically, do you have any thoughts about addressing
53:48
the lack of a reliable public transportation system in San Antonio?
53:53
So for one, I'm actually from San Antonio, but I'm an Army brat.
53:58
My dad was an Army pediatrician, by the way, pediatric allergist.
54:01
And then as in my own career as an army healthcare administrator, moved around the world.
54:05
So I have been blessed to enjoy great public transportation in many,
54:09
many places. San Antonio is not one of them.
54:12
And it's very unfortunate. You know, we actually had a streetcar system back
54:16
in the 1920s and they took it all out when they focused on cars for everybody,
54:20
which is, you know, is not adequate.
54:22
And so, you know, the via bus system is trying to improve and find ways.
54:27
We had a chance over a decade ago to actually put in a transportation system,
54:34
a light rail system for us here in San Antonio.
54:37
Unfortunately, the decision makers were not the ones that used the system or would have used it.
54:41
So that voice was not represented and we lost that opportunity again.
54:45
I don't know if we'll ever get it back, but that really needs to happen down the road.
54:49
We are the largest city, seven largest cities in the United States and the largest
54:53
city by far that does not have a strong transportation system, a light rail system.
54:57
So that is something that, you know, when we talk, I talked about what can we
55:01
do to change the negative downstream effects?
55:03
We've got to work on improving laws, regulations, policies, ordinances,
55:08
et cetera, that will help, you know, equalize opportunities for everybody.
55:12
Because this is a disparity that ties into health as well.
55:16
So, you know, that's just a future voice that we all have to come together on,
55:20
even if we might not be the ones that would use it that much, we need to be.
55:24
Because those who are older, those who are poor, those who are disabled,
55:26
those are all folks that rely on public transportation or they don't get around
55:31
at all and their world is very small.
55:34
Then there's a question about school vouchers. This is, it says,
55:37
how do you think school vouchers would impact the public education system that
55:40
serves the most vulnerable children?
55:42
Great question. I try to stay out of politics, but I can tell you this will
55:45
be a huge detriment for our state if that were to come to play.
55:49
Because primarily those that use the private schools right now,
55:53
they're ones that had already made that choice and can afford it or get scholarships
55:58
already through a lot of those schools.
56:00
And as I mentioned, the public school system is where over 85% of our children
56:07
go, especially our low income families here.
56:10
And many of them still would remain in the public school system.
56:13
And because the school vouchers would come out of what is already being funded
56:19
for public education, that means, and we are funded per day.
56:23
It's based on child attendance. So if we have fewer students in schools,
56:27
that means less funding for those school districts.
56:30
We're seeing that already just coming out of the pandemic where there's a lot
56:34
of kids that still did not go back into those school systems.
56:36
We've seen that with movement, with the growth of charter schools.
56:40
And when you look at the accountability requirements and the certifications
56:46
required for teachers, you know, in public schools versus charter schools versus private schools,
56:52
what people don't realize is that we are not holding everybody to the same standard.
56:57
The public schools are held to the highest standard and the most visible,
57:00
but they don't see what's going on in the charter schools or in the private schools.
57:05
In addition, private schools can select who they choose to admit.
57:10
So in there, kids that have disabilities, you know, kids that are struggling
57:15
are not ones that are likely to be admitted.
57:17
That's already been shown in many of the charter schools out there.
57:21
You know, those are the kids that stay in the public school system.
57:23
And we already know that we don't have adequate supports for those with disabilities
57:28
and supports in Texas and the public school.
57:31
So there is a huge risk with the school voucher system.
57:35
And when they looked at it being implemented in a couple of other states,
57:38
they are seeing the research is starting to show the detrimental effects on
57:43
those kids not having enough funding to be able to meet their needs.
57:48
And Texas already was one of the lowest funded states per student in our public school system.
57:54
And it's just getting worse. So we need to be a voice is my recommendation on
57:59
helping to ensure that our public schools continue to have sufficient funding
58:03
and more than sufficient funding, because that's what will serve our children,
58:08
you know, on the health side, but on the on the financial side to be able to
58:12
be prepared for the workforce, either through college training,
58:16
career development, etc.
58:18
Right. Thank you very much, Mary. You really covered a lot of ground in a short amount of time.
58:23
I know that was a challenge to fit it all in. We are at the end of our time.
58:27
So thank you one more time for speaking. And this concludes our Pediatric Grand
58:31
Rounds. Thank you, and my pleasure.
58:34
We hope you've enjoyed this episode of Pediatrics Now.
58:37
Click on the link for free credit if you're a practitioner. You can also email
58:41
us with questions or episode ideas.
58:44
That address is PediatricsNow at U-T-H-S-C-S-A dot E-D-U.
58:50
We release a new episode every Friday. I'm Holly Wayman.
58:54
Music.