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For the Love of Children
How do you deliver comprehensive health care
to children and youth in the inner city?
And if you do, does it do any
good?
We absolutely know how to do it, and we have
proved that it works!
Part of that
effort emanated from tiny offices above Stub & Herb's Bar on
Washington Avenue in Minneapolis. When those quarters got too
crowded, we moved to a warehouse a block away. You had to get
there early if you wanted a desk. Otherwise, you had to go to
the library to do your work.
Ultimately, a
staff of more than 100 persons comprised of graduate students,
office support and senior researchers / practitioners all the way up
to the venerable and irascible Dr. Vernon E. Weckwerth, was
assembled to work at Minnesota Systems Research, Inc. (MSRI).
It was a think tank affiliated with the University of Minnesota. We
were different from the other organizations in our type of work in
that we always implemented what we dreamed up. And
that, I can assure you, is a sobering experience. I was in
charge of the Research Division; my average workweek was 93
hours.
"So, what is
comprehensive health care?" you may ask.
It is
complete care, and that means medical,
dental, nursing, social work,
psychological, occupational therapy, nutrition,
physical therapy and speech and hearing.
It is
continuous care, and that means that each child or
youth has a care plan that is worked out by a team, and
includes all the care personnel that are needed to deliver that
care. It means planned care for chronic conditions or
regular health assessments, and it means episodic care for
unpredictable events.
It means knowing
where each client is in the care cycle at any time. It means
going into the homes of children and dealing with the hygiene,
nutrition, medication and education that are needed to keep them
healthy. It means getting to know everyone.
Is this so
hard?
If I told you that
the annual cost of care per child went down each year over the seven
years that I worked there while at the same time, measures of health
improved, would you believe me? Do you know of any other
health care program, with more than half a million children
enrolled, where the children got healthier and the
costs went down? …At the same time?
I don't know of any
other.
We could explain
the cost variations among all the clinics since we knew how many
children there were in each location (that explained 46 %) and the
capacity filled (that explained 30 %). The geographic location
and clinic affiliation (hospital, university or health department)
contributed more to the explanation. Measures of care
delivered and outcome registered explained the rest. A total of
about 30 variables were the keys to understanding clinic operations
although, as you will learn shortly, the most important predictors
of success were not measurable.
If we inserted the
values of the variables that were linked to the cost of care into
the database for any clinic, we could find out whether their costs
were higher or lower than expected. This difference,
e.g., if it was too high or low, we could break down into
what likely had caused its occurrence. Then we could send an
expert team to that specific location and help improve children's
health by removing those obstacles to care so that the desired
outcomes our data revealed as being possible, could be
achieved. Invariably, productivity improved, cost went down
and the children got better as a result of these visits.
All this we did
with a health care information system that was easy to explain, easy
to use, and completely transparent as to what took place inside the
clinic. The number crunching was done at the University of
Minnesota Computer Center on a CDC 6600, then the world's largest
computer.
All this is
documented in nearly 800 papers and publications. And those of
us who were privileged to work there have not forgotten.
When Detroit burned
during the riots of 1967, black militants stood guard around our
clinics. These clinics were their health care providers.
These clinics gave pre-natal care to pregnant mothers, some not much
older than children themselves; saw to it that the newborn infants
were properly cared for, fed and protected; and improved their
health. We
were the first to show that each dollar spent on a nutritionist
saved $7 in medical care. We were the ones who documented
hunger in the U.S. by precise caliper measurements of children,
created height-weight-age-race growth charts, and then helped in the
fight for healthy school lunches. We were the ones who found
lead poisoning in children and proved that it came from automobile
exhaust — not from eating lead paint. That's why cars have
catalytic converters today, and that's why air quality eventually
improved in the inner city, far beyond anyone's expectations.
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Dr. Paul Ellwood
visited our offices often, trying to write legislation that would
capture what was taking place in these clinics. We talked
about a Health Maintenance Strategy ("HMS"), which was changed to
"HMO" in visits to the US Department of Health, Education and
Welfare. He helped get the HMO Act of 1973 passed, but the law
did not really capture what was happening in the clinics. What
happened there eluded measurement.
But what happened there was so simple, so
common sensical, so logical, and so right.
Yet that is
still not why health improved and cost went
down.
That resulted from the bonding that occurred
among teams made up of key indigenous staff, the health
professionals who saw their tasks as a calling, and parents who
loved their children. They loved them so they would not fall
for the deadly seductions of the drug dealers, or drop out of
school, or ignore their health. When the care teams combined
their insights about particularly difficult cases, nothing seemed
impossible.
Why don't we do
this everywhere?
During my time at
MSRI, I must have personally visited at least 50 clinics, some of
them many times. I went to each clinic armed with data that
were like an organizational MRI. I knew, before I even got
there, how every one of those clinics worked in every functional
area, and where the bottlenecks were. I also knew that the
clinic would welcome any feedback that they could use.
It was useful to
know this, of course, but I didn't think I had to spend more than a
couple of minutes in any clinic to know whether it was well run and
delivered effective health care. That happened in clinics
where the staff were quick and certain about their duties, where
there was empathy and respect for the patients, where each staff
member knew that she was considered to be important to the mission
of the clinic, and where everyone felt safe and proud and justly
treated. These variables are very difficult or perhaps impossible to
measure, but they are key to the success of any
organization.
Our health is
largely our own doing. About 50% of what we'll suffer from
comes from what we do to ourselves — or not for
ourselves. Data from longitudinal studies in health show that
the love of parents is crucial if their children are to avoid
serious mid-life diseases. Satisfaction is strongly correlated
with health to the extent that it may protect us against
circumstances that can, literally, make us sick.
What Dr. Paul
Ellwood could not capture in the HMO Act of 1973, was satisfaction
and, yes, love. We all saw it, felt it, and experienced
it. It was love of work, love of children, and the
satisfaction that resulted from having good information, and good
cooperation in achieving what the information revealed had to be
done …a passionate commitment.
I bow my head in
respect to the Children's Bureau's comprehensive health care
adventure. They taught us how to improve the health of
children in the best possible way. The Bureau was on a quest,
and everyone joined in. Yes, everyone!
If you visit Dr.
Vernon E. Weckwerth in his office, you might spot him among the
stacks of papers, books and reports that are overflowing his
office. But in that apparent chaos of information, Vernon
always knows where everything is, and that is logical, of course,
because everything is in that office. The records, the
research, and the evidence that good care does not need to be
costly, and that good results come from good and timely information
that is acted upon.
Vernon is known for
not suffering fools gladly. The reason we all worked so hard
and so long was that he worked even harder and longer, and if we did
not meet his standards, Vernon could be quite difficult to work
for. There is another reason as well.
Last summer, he
taught a class for me about all those years we spent in the inner
cities of this nation. I had just undergone major surgery, but
managed to attend his presentation. It was the best he had
ever given.
It was then that I
saw what had fueled Vernon's maniacal drive to improve the health of
children.
I noticed a little
quaver in Vernon's voice. His eyes got a little shiny.
He was back in that crowded space in that warehouse building on
Washington Avenue. He suddenly realized how much he had loved
it and how much good had resulted from his work. How he missed
it all! He had been part of something very special; and so had
we.
The principles of
care that were used in those clinics are timeless. It would be
far easier today to do what was done then.
So, why don't we do
it? Now? Everywhere?
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