Caring for Our Kids: How OHSU is Addressing Psychosocial Needs in Complex Pediatric Patients

Children with serious medical conditions can also face complex psychosocial challenges and barriers, including food and transportation insecurity and housing instability. In this new “Caring for Our Kids” episode, David Wagner, Ph.D., pediatric psychologist at OHSU, discusses the Novel Interventions in Children's Healthcare (NICH) program, and how this innovative approach is transforming care for vulnerable children.



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00:00:00:18 - 00:00:27:25
Tom Haederle
Welcome to Advancing Health. Coming up in today's episode, a conversation with a pediatric psychologist about the psychosocial challenges for kids with complex medical needs. The challenges can be many: Missed school, food insecurity, transportation issues and others. Our host is Julia Resnick, director of Strategic Initiatives with H.R.

00:00:27:27 - 00:00:33:12
Tom Haederle
Julia, over to you.

00:00:33:14 - 00:00:42:12
Julie Resnick
So I'd love to start with learning a little bit more about you and the work that you do. Can you introduce yourself to our listeners and tell us just a little bit about your professional background and interests?

00:00:42:14 - 00:01:07:02
David Wagner, Ph.D.
Sure, yeah. Again, my name is David Wagner. I'm a pediatric psychologist and a clinician scientist. Very passionate about and interested in ways to identify youth at risk of health and life inequities, as well as evaluating programs and developing programs that can address those inequities. Work at OHSU and in Dawn Becker Children's Hospital. We are the top ranked children's hospital in Oregon.

00:01:07:02 - 00:01:28:07
David Wagner, Ph.D.
We serve a population of roughly 50% youth on Medicaid. We don't just serve the state of Oregon, but also southern Washington, northern California and Idaho. I particularly work in the Department of Pediatrics. With the Novel Interventions and Children's Health Care Program, where we work with young people who have a combination of medical complexity and high social risk.

00:01:28:09 - 00:01:34:18
Julie Resnick
So talk about that a little bit more. What are some of the psychosocial challenges for kids with complex medical needs?

00:01:34:20 - 00:02:08:22
David Wagner, Ph.D.
It's a great question. I mean, just in general, we know that kids with complex medical needs already have to engage in really complicated disease management. Miss school for attending medical appointments. They and their caregivers spend a lot of their day engaged in care. Outside of everything else, that's tricky about being a young person. In addition, we actually have a subset of young people who have complex medical conditions who also experience high levels of food insecurity, houselessness, exposure to domestic violence, transportation challenges that make it nearly impossible to engage in recommended care.

00:02:08:24 - 00:02:26:28
Julie Resnick
Yeah. So if it wasn't hard enough to be a kid with a complex medical issue, to have all those other issues surrounding your family and your community, it's just got to be really challenging for those kids. And I think that all leads us to the work that you do with NICH. So can you tell us about the program and what its origins were?

00:02:27:00 - 00:02:51:07
David Wagner, Ph.D.
Yeah, another great question. So this is a little over ten years ago, I had yet to come to OHSU. Dr. Michael Harris, he's our pediatric psychologist who leads our inpatient consult service. And so when young people are admitted to the hospital for reasons that the medical team believes is avoidable, they call in our inpatient console team to try to help understand what are some of the challenges experienced outside the hospital, and how can we help improve the child's health.

00:02:51:09 - 00:03:10:22
David Wagner, Ph.D.
Even with all of his advanced training and experience, he identified that there was a group of youth where there were no medical interventions or mental health or behavioral health interventions that were going to effectively change the factors that were driving the health problems that they are experiencing. The health problems they're experiencing were happening outside the hospital, in the communities, in the neighborhoods. In general,

00:03:10:22 - 00:03:37:09
David Wagner, Ph.D.
these youth experienced just a lot of social challenges, as did their families who were doing the best they could. And so I think any innovation comes from that combination of passion, frustration and curiosity. How can we do this better? And so Dr. Harris, Kim Spiro, they co-developed this program NICH, where we deliver services to the community in the homes of the youth who are experiencing medical conditions and social risk, to address the inequities they're experiencing.

00:03:37:11 - 00:04:09:17
David Wagner, Ph.D.
Often it's how do we find stable housing? How do we find secure food that you can reliably depend on? How do we help you gain access to transportation? We go with young people to their schools. We go to them to the mall. We meet their friends, we meet their extended family, and we work closely with the medical providers here at OHSU and other medical centers, just to better understand the challenges that families are facing and collaborate to help ensure that we're all on the same page and can help support them in managing their medical condition at home.

00:04:09:19 - 00:04:24:15
Julie Resnick
Yeah. I often like to say that people are only patients for this short, finite period of their life and the rest of who they are is everything outside of the hospital. So can you talk a bit about what kind of support and services kids and their families receive when they're part of the program?

00:04:24:18 - 00:04:43:09
David Wagner, Ph.D.
Yeah, it's a combination of services. We really like to tailor our services to family needs. The providers who go out into the home, they are not mental health providers. They are not medical providers. We call them interventionists. And what they do is they first assess the needs the families have and then they tailor their services depending on what families tell them.

00:04:43:10 - 00:05:11:09
David Wagner, Ph.D.
So for some families, it's really intensive case management. How do we figure out how we can get you access to the resource, to resources to address basic needs so that we have more time and energy to manage the medical condition? For others, it's making sure that all of the different providers involved in their child's life are providing consistent recommendations across providers and also making sure that the family and providers are interacting in ways that the family is able to and interested in accessing care and following through with recommendations.

00:05:11:12 - 00:05:28:26
David Wagner, Ph.D.
And a lot of what we also just do is reinforcing all of the efforts that they're already doing to try to manage their medical condition and then working with them in the other environments that they live to ensure that the insulin gets in the body, that they're able to follow the recommended dietary plan and engage in other parts of the medical care that are recommended.

00:05:28:28 - 00:05:39:12
Julie Resnick
Let's talk a little bit about the care team. I know that your team has child psychologists and interventionists, but who else is part of the care team? And how do you all work together when caring for patients?

00:05:39:15 - 00:06:00:14
David Wagner, Ph.D.
We work really closely with our specialty and primary care providers, especially here at OHSU. They are super invested in these families and so they're often providing us with guidance and education on what that medical regimen would look like at home, so that when we're out in the home, we can support the family in their, their efforts to engage. Our team, our interventionists come from all walks of life.

00:06:00:17 - 00:06:19:10
David Wagner, Ph.D.
We've recruited folks from Starbucks. We've recruited people who are working for other community agencies interested in populations that are less represented, making sure they get equitable care. The common theme is that the folks who work on our team are all heavily invested and passionate about this population. And we like to refer to them as social chameleons:

00:06:19:10 - 00:06:36:25
David Wagner, Ph.D.
they're able to walk into a physician's office and briefly and quickly summarize patient care in a way that they're taken seriously, but then walk into a family's home who's living in poverty and take their time and slow down and connect and better understand the family's lived experience. So, there's really a diverse range of individuals who work with our team.

00:06:36:27 - 00:06:51:07
Julie Resnick
I love that idea of a social chameleon and just needing people who can be adaptable in different situations. So I want to pull on that thread about schools. You mentioned that these are one of the organizations that you partner with a lot. What does that partnership look like?

00:06:51:09 - 00:07:08:04
David Wagner, Ph.D.
Yeah. You know, the schools we've worked with have been heavily invested in the youth health. We actually work a lot with school nurses, so a lot of our young people have to go to the nurse to get their medication or to take their insulin. And so a lot of what we're doing is working with those in the schools who are directly interacting with the youth.

00:07:08:06 - 00:07:21:22
David Wagner, Ph.D.
A lot of our kids have been missing school, too, or having difficulties attending school because of their medical condition. So we work with school staff to help get them caught up, to make sure that the accommodations that they need are in place. And just in general to support their education.

00:07:21:25 - 00:07:32:20
Julie Resnick
So by now, I think our listeners are probably wondering, how do I do something like this in my organization? So my question for you is, how do you get this off the ground? What do they need to do to get started?

00:07:32:22 - 00:07:51:24
David Wagner, Ph.D.
It's a complicated process. You know, what we've learned is that in the beginning, often having philanthropists seems to sometimes be the best way. Having somebody in your community who says, I really care about this population, whether it's because they just are very invested in health equity, or maybe they have a close family member they themselves who have a chronic condition.

00:07:51:24 - 00:08:05:27
David Wagner, Ph.D.
And they imagine to themselves, wow, what would that be like if I had this or my child have this, and we didn't have secure housing and we didn't know where our next meal would come from, or we were trying to adapt to a new culture. Part of it is engaging those who really care about this population.

00:08:06:00 - 00:08:25:26
David Wagner, Ph.D.
Another part of it is working within an institution that truly cares about health equity and is willing to, essentially put their money where their mouth is. So we don't make money for OHSU. They see the benefit to their patient population. They see the benefit to their medical providers who can sleep well at night. And they generally just see the benefits of their institution as a whole.

00:08:25:28 - 00:08:45:06
David Wagner, Ph.D.
Once we start building a team and launching, what we tend to find is over time, that we are able to get revenue from other sources as well. A lot of local Medicaid entities are interested in kids staying out of the hospital. And so they become invested in that and they'll contribute funding. And we also have larger research foundations that also contribute.

00:08:45:08 - 00:08:54:14
David Wagner, Ph.D.
Leona M. and Harry B. Helmsley Charitable Trust has been one of our biggest supporters. And they've actually helped us spread not only here in Oregon but to the Bay Area in California.

00:08:54:17 - 00:08:59:15
Julie Resnick
Let's talk more about impact. How do you know that you're making a difference for the kids you're serving?

00:08:59:18 - 00:09:16:25
David Wagner, Ph.D.
Yeah. No, it's another really good question. You know, when we got into this, this work, a lot of it was really focused on like, number one is how do we help these kids and families get the outcomes that they want? And so first, understanding from them what's most important and how to get their needs met and address any life inequities they're experiencing.

00:09:16:27 - 00:09:46:02
David Wagner, Ph.D.
We've increasingly focused to collect data that  is most important to the stakeholders who then fund programs like this. So we're very focused on the quintuple aim. We measure lab values and other physical findings to understand the patient's experience, improved health. We look at the kids experience fewer emergency department visits and admissions for avoidable reasons. We talk to our medical providers and give them surveys to assess provider burnout and improve quality of life they experience when they're not up late at night thinking about kids that they're worried about.

00:09:46:05 - 00:10:08:02
David Wagner, Ph.D.
We also look at attendance. We found that youth in the program are much more likely to attend outpatient visits, and they're much less likely to no show, which is really good for them, but also good for the medical community. We also find that when one of the one of our studies looked at youth of color and essentially found that the youth of color referred to our program had roughly half the access to care of non-Hispanic white youth.

00:10:08:07 - 00:10:29:22
David Wagner, Ph.D.
And then we looked at two years following program involvement. We saw that that disparity in access had completely disappeared. And so for sites who are invested in health equity, we have we have outcomes that demonstrate that the NICH bridges that gap. We also do focus to some degree on medical costs. And we find that there are substantial reductions in medical costs that benefit primarily insurers, but also, institutions.

00:10:29:22 - 00:10:34:07
David Wagner, Ph.D.
So we look at a wide range of outcomes to meet that quintuple aim.

00:10:34:10 - 00:10:45:19
Julie Resnick
I love that focus on designing care around the specific needs of kids and their families. So I'd love to hear more about those kids and families that you're serving. Do you have any stories that could bring this to life?

00:10:45:21 - 00:11:08:18
David Wagner, Ph.D.
There are more stories than I have time to share. A couple of young people come to mind. Often insurance providers will pay for this intervention after a youth has been hospitalized numerous times and has experienced multiple complications that are really costly. We will sometimes argue that, wouldn't it be great if we actually started investing in these children before they have these costly complications?

00:11:08:18 - 00:11:30:01
David Wagner, Ph.D.
And so this is actually one example where an insurer did pay for the program prior to any costly complications. We had a four year old girl who was newly diagnosed with Type One diabetes, who was living with her father, who was experiencing houselessness and who was also in recovery. All of the places that they could stay had people who were using there, which made it difficult for father to stay sober.

00:11:30:05 - 00:11:49:15
David Wagner, Ph.D.
And at the same time we couldn't find any shelters that would take in single dads with children. Our interventionists worked closely with dad to get him into needed mental health and recovery services. He was able to find a place that would take them in where nobody was using, and ultimately was able to sort of assess where is social support in this community

00:11:49:15 - 00:12:06:00
David Wagner, Ph.D.
and ultimately, when we found that there wasn't social support in the nearby community - but we were able to contact and reach an extended family - we were able to work with the insurance company to help the family access that support and secure housing. And that's one example. You know, there's another example that comes to mind of a kid who was experiencing lots of frequent infections.

00:12:06:00 - 00:12:29:09
David Wagner, Ph.D.
The two year old girl who was having multiple line infections. And when the interventionist went out to the home, she noticed that the living conditions were such that you would expect a lot of infections. The family was doing the best they can. Multi-generational family, and numerous family members had the skills to essentially, like, replace the carpeting and the flooring and whatnot, but they didn't have the resources to have the materials to do so.

00:12:29:09 - 00:12:47:03
David Wagner, Ph.D.
And so she actually worked with the local hardware store who donated supplies after hearing about the family situation, got those to the family. The family replaced the flooring and was able to replace other parts of the house to improve the living conditions. And next thing you know, this this young child was no longer experiencing these dangerous complications.

00:12:47:05 - 00:13:10:05
Julie Resnick
Those are both such powerful stories and I think really go to show how important it is that people have a stable place to sleep at night, that they have access to food. Because if you're worrying about all those basic needs, how can you be worrying or taking care of your own health or your kid's health? I really appreciate how your work ties all those medical and social needs together to really give kids the best care possible.

00:13:10:07 - 00:13:23:23
Julie Resnick
Dr. Wagner, thank you so much for sharing your time and your expertise with us. I just really appreciate the work that you do and your commitment to kids in your community, and trying to give them the best shot at a healthy life, now and in the future.

00:13:23:25 - 00:13:26:12
David Wagner, Ph.D.
Thank you, Julie, and thank you for your time and excellent questions.

00:13:26:14 - 00:13:28:26
Julie Resnick
Thank you so much.

00:13:28:28 - 00:13:37:10
Tom Haederle
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