December 2006

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The "rainbow" connector

Liza Hirsch with Matthew (left) and Damian Wray

Care Coordinator Liza Hirsch sees families through tough times
Sometimes a child's health care needs extend far beyond what a health care provider can accomplish in the examination room. In fact, nearly 40 percent of patients seen in Children's Hospital Boston's Primary Care Center (CHPCC) are chronically ill, high-risk patients from low-income families. "It can be overwhelming to negotiate the health care system, manage your child's multiple needs, understand the expectations of the various providers, support your child and manage your family, work and life," says Harriet Sanclemente, RN, PNP, who works in the CHPCC. Because of this, CHPCC has developed The Rainbow Program, based on a national model called Medical Home, which aims to provide comprehensive health care by helping families with all matters that affect their child's health.

That's where Care Coordinator Liza Hirsch steps in. Her position, which is arranged through the Massachusetts Department of Public Health, is part of the CHPCC's Rainbow Program. "The basic idea is that quality health care continues outside the hospital," Hirsch explains. Her efforts help connect patients and their families to resources they may not be able to find on their own.

Hirsch becomes deeply involved in a patient's life once a clinician recognizes that a family needs support. She begins by interviewing the patient and family—usually visiting their home to get an in-depth sense of their needs. "Families living in poverty face unique challenges, so we need to take into account the child's social, cultural, physical and psychological circumstances," she says. "Conducting a home visit is an important way of connecting with the family and understanding the child's full context."

Once she understands the family's specific needs, Hirsch becomes that family's "glue," as she calls it, between the various agencies the family deals with. She also communicates between the patient's many doctors about the child's physical and mental health, working with CHPCC providers to form a team approach to the child's care. Hirsch is tireless. An expert in community resources and supplemental funding sources, she's determined to get families help on everything from affordable housing to medical insurance to immigration issues.

One family Hirsch works with is the Wrays, who lost everything they had after riding out Hurricane Katrina. Collette Wray is a single mother recovering from domestic abuse. She and her two sons bounced from shelter to shelter after the flood, eventually landing in Jamaica Plain, Mass. Her 9-year-old son, Damian, started treatment at Children's for several physical problems, as well as attention-deficit disorder, pervasive developmental disorder, post-traumatic stress disorder and bipolar disorder. When she met Hirsch, Collette was at the end of her rope. Damian had been moved from school to school in the Boston area and was reacting badly to the constant transitions. Colette had been put in contact with some agencies but still wasn't getting what she needed, which was someone to connect it all.

"The first time I met Liza, she gave me a big binder of all of Damian's appointments," Collette says. "It was great. She'd organized all of his information from his cardiologist, urologist, primary care doctor and psychiatrist. Any time I don't know what to do about his medical situation, she finds out and tells me what to do."

In the many months they've worked together, Hirsch has become Damian's advocate on every level. She meets him, Matthew and Colette during his many Children's appointments. She also found them subsidized housing in Newton and got Damian into a school program suitable for his pervasive developmental disorder—something Wray had tried to do but was unsuccessful. "She's persistent," Collette says. "Liza talks and people listen."

The Wrays are one of Hirsch's 55 current cases—and CHPCC has identified at least 500 others who qualify for help. To help meet this need, and to further the Medical Home model of care, the department just created a new position and hired a nurse practitioner to join the Rainbow Program team, which inlcudes doctors, nurses and social workers.

"It would be hard to imagine ourselves without someone like Liza in the future," Sanclemente says. "She represents one of the best quality improvement efforts we've made in CHPCC."

Collette and her two boys couldn't agree more. "She's my friend," Wray says. "Any time I need to talk or get advice, I call her. Now, my future is looking a lot brighter."

:: Erin Graham, Editor :: Masthead ::

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