School of Medicine
200 North Wolfe Street
Division of General Pediatrics & Adolescent Medicine
David Rubenstein Child Health Building, Room 2074
Baltimore, MD 21287-3144
Phone (410) 614-8438
Fax (410) 502-5440
The Harriet Lane Clinic at the Johns Hopkins Children’s Center
The Harriet Lane Clinic (HLC) is a comprehensive, multidisciplinary primary care clinic
that serves two complementary missions:
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To provide high-quality care to its patients; and
To provide a high-quality educational experience to pediatric trainees in the
ambulatory setting.
To achieve this dual mission, HLC is functionally divided into 4 clinics: a continuity clinic,
an acute care clinic, an adolescent clinic, and a clinic for children and adolescents
infected with or affected by HIV (Intensive Primary Care, IPC). Three of these clinics
(continuity clinic, acute care clinic, and adolescent clinic) are staffed primarily by
pediatric residents with faculty supervision, and each of these three clinics delivers a
structured didactic curriculum to its trainees in addition to teaching in the context of
patient care. Each year approximately 60 residents (3/4 of the 80 pediatric residents
that comprise the Johns Hopkins pediatric residency training program) are assigned to
the HLC for their continuity clinic experience. This academic year (2011-12) we have 63
residents. Residents spend ½ day per week over their 3 years of training in the HLC
where they function as a primary care provider to a panel of infants, children and
adolescents. Each continuity clinic group functions together as a group practice and has
an assigned continuity clinic preceptor (attending pediatrician). This preceptor remains
with the group for the full academic year and, as much as possible, for subsequent years
of training, reflecting the priority we place on the continuity between preceptors and
residents.
Over 16,000 patient visits take place per year in the Harriet Lane Clinic, including health
maintenance, follow up and acute care visits. The HLC serves as the medical home to
approximately 5500 children from birth to 13 years of age and 3000 adolescents 13 to
21 years of age, most of whom live in the adjacent East Baltimore community. Patients
are predominantly African-American and nearly 90% are eligible for public insurance
through Medicaid or S-CHIP (which are administered in Maryland as a single program
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known as “Medical Assistance”). Nearly 40% of our patients have chronic medical
conditions and many patients can be categorized as children with special healthcare
needs (CSHCN). Most of our patients and families experience major social and financial
challenges associated with living in poverty, including issues of substance abuse,
homelessness, unemployment, and mental health problems.
Due to the enormity and range of our families’ social and healthcare needs, we have
expended considerable effort over the last several years to bring an array of on-site
multidisciplinary services to HLC. These services include a dental clinic, a youth fitness
program, nutrition counseling, a WIC office, child life specialists, a safety resource
center, reproductive health services for adolescents, social work services, mental health
services for children and caregivers as well as a Family Resource Desk (Health Leads)
with staff and student volunteers linking families to community-based resources.
Family-Centered Mental Health Services
We offer a wide range of on-site mental health services to our patients. They began
several years ago with the addition of a single on-site practitioner (HLC Mental Health
Consultant), funded by the Aaron & Lillie Straus Foundation. Our HLC Mental Health
Consultant is available to perform mental health screenings of patients, educate
residents, and facilitate referrals to community-based resources. With funding from the
Straus Foundation and additional support from the Jacob & Hilda Blaustein Foundation ,
the Leonard & Helen R. Stulman Foundation and the Harry & Jeannette Weinberg
Foundation our ability to provide on-site mental health services for children,
adolescents and their families has grown considerably over the years. We now have a
full time Family Support Counselor (licensed social worker) who assists residents and
other healthcare providers in screening mothers of newborns for post-partum
depression and intimate partner violence, and linking mothers to appropriate mental
health treatment and community-based resources. Similar to our HLC Mental Health
Consultant, the Family Support Counselor is heavily involved in educating residents and
providers and facilitating referrals. Furthermore, we now have part-time mental health
clinicians who provide services to children with mental health problems and mothers
identified as having post-partum depression. Our efforts to add on-site providers were
driven by a confluence of factors. First, we found that our residents, with the aid of
screening instruments and on-site mental health consultants, were identifying many
children and mothers in the postpartum period with active mental health issues.
Second, we found that despite the advocacy of our residents and on-site consultants,
families were often not becoming successfully linked to community-based resources.
Legal Education and Advocacy: Project HEAL
Project HEAL (Health, Education, Advocacy and Law) is one of 60 medical-legal
partnerships in the United States. It was created in 2003 through a partnership
between HLC and Maryland Volunteer Lawyers Services, and is staffed by a full-time onsite attorney. Because it is physically located within the HLC, the program provides
clinic families with ready access to legal advice and representation. Just as importantly,
it provides both formal training and informal consultations to residents and other clinic
staff on legal issues commonly encountered by low-income families. These issues
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include landlord-tenant issues, school enrollment and special education matters, denials
of public benefits, custody and guardianship issues, consumer debt collections, and wills
and advanced medical directives. We conduct ongoing tracking of the number and types
of cases handled by the project, as well as sources of referrals.
Family Resource Desk: Health Leads
Also located within the HLC, the Health Leads (formerly Project HEALTH) Family
Resource Desk (FRD) uses a visit to the doctor’s office as an opportunity to connect lowincome families with critical government and community resources, such as health
insurance, food, housing, fuel assistance, and job training. Staffed by undergraduate
student volunteers, Project HEALTH works with families to negotiate the diverse,
fragmented landscape of available resources, to identify the most useful set of services,
and to provide them with up-to-date information. All patients and families coming to
the HLC for a continuity clinic visit complete a very brief psychosocial needs assessment
prior to seeing the resident provider. The needs assessment empowers residents to
discuss these sensitive issues further and refer patients to the FRD or other clinic-based
resources. At the FRD, student volunteers perform a more in-depth psychosocial
assessment, connect families to services and resources and provide follow up to ensure
they obtain the resources they need and to address any hurdles they encounter. As
with other on-site programs, we actively track the types of referrals made and the
number of families served. Between October 2006 and December 2008, the FRD
assisted over 840 clients presenting with over 1,700 psychosocial issues. In a research
study conducted by pediatricians and FRD volunteers at the Harriet Lane Clinic, and
presented at the 2008 Pediatric Academic Societies meeting, 90% of surveyed families
were satisfied with the resources provided by the FRD and 63% of families had
contacted community programs and 32% already enrolled in community programs
within 6 months of their FRD visit. Project HEALTH staff are also conducting a number of
issue-specific projects, including linking uninsured patients to health insurance and
improving feedback to referring pediatric providers.
Safety Lane: Safety Resource Center
Located off the waiting room of the HLC, Safety Lane offers injury prevention education,
services and products to patients and staff. Based on the Children’s Safety Center in the
Johns Hopkins Children’s Center, faculty from the Bloomberg School of Public Health
and faculty in our Division created Safety Lane. The center is staffed by a health
educator who is also certified as a child passenger safety technician. Our health
educator position is funded by Johns Hopkins HealthCare. Safety Lane provides free of
charge the opportunity for one-on-one counseling about injury prevention as part of
routine pediatric care provided in the clinic. A variety of educational materials,
designed in-house to be appropriate to the cultural and reading level needs of our
patient population, are distributed to visitors and reinforce the main messages provided
in individual sessions. Inside Safety Lane are several exhibits designed to highlight the
common hazards found in a typical home and to offer more hands-on opportunities to
engage visitors to promote child safety. For instance, a stove is available to highlight
common fire and burn hazards. A variety of cabinets (in kitchen and bathroom) show
where household poisons are often found. A non-working sink, bathtub and water
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heater highlight possible fall, drowning and scald burn risks. A set of stairs provides the
opportunity to discuss fall prevention and stair safety. Most of these exhibits also have
on display a safety product “in action.” For instance, the oven has been outfitted with
stove knob covers and an oven locks to show how these items can be used to prevent
childhood burns and residential fires. Two stair gates are displayed at the top and
bottom of the stairs to show the proper type and position of safety gates. Various
cabinets and drawers latches are used to allow parents to practice see the variety of
designs available and to help them select the appropriate one for their homes. A bath
tub thermometer and non-slip decals are used to educate visitors about the products
available to prevent scalds, falls and drowning incidents in the tub. A car safety seat
demonstration chair equipped with various seatbelt types as well as the LATCH system
allows our certified child passenger safety technician to teach families who do not have
their own vehicle how to properly secure their children. Each of the exhibits vividly
depicts common household hazards and provides visitors with hands-on experiences to
learn how to properly install and use recommended safety products. One of our senior
pediatric residents obtained funding for a bicycle safety program. The Baltimore Bike
Helmet Program is run out of Safety Lane. The program offers free bicycle helmets to
children during a visit to the resource center.
HLC Program for Children with Special Health Care Needs
In 2008, we received funding from the Maryland Department of Health & Mental
Hygiene Office for Genetics & Children with Special Health Care Needs (CSHCN) to
develop a sustainable model of coordinated, longitudinal, comprehensive care within
the medical home for CSHCN. The program focuses on children with high prevalent,
high impact and/or high cost conditions including asthma, attention deficit hyperactivity
disorder (ADHD), sickle cell disease (SCD) as well as children with other medically
complex conditions including diabetes and developmentally disabled children. We have
a special needs case manager who works closely with providers and clinic staff to
improve health outcomes for those in our CSHCN registry.
We partner with Johns Hopkins Healthcare Priority Partners, a large managed care
organization serving 116,000 Medical Assistance enrollees. Through this collaboration
we have been able to add appropriate patients to the CSHCN registry and specifically
assess pharmacy and health care utilization data for these children. Our HLC special
needs case manager works closely with our pediatric residents by providing important
feedback about their patients’ medication refills and health care utilization (well, acute
and emergency department visits and hospitalizations). The case manager assists
residents with communicating with specialists and school personnel. The overall goal of
this program is to improve quality of and satisfaction with medical care for families of
children with special health care needs by providing coordinated, family-centered,
comprehensive care within the child’s medical home.
One of the key objectives of the program is to train our residents about providing a
medical home for CSHCN and disseminate a sustainable model of coordinated
comprehensive care for CSHCN to other Priority Partners practices in Maryland, other
insurers, and national pediatric organizations. We have added formal continuity clinic
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teaching sessions on ‘Primary Care & Health Supervision Guidelines’ and ‘The Medical
Home & Caring for CSHCN.’ Through the creation of our HLC CSHCN patient registry we
are able to identify the percentage of patients assigned to each of our residents with
asthma, ADHD, sickle cell disease as well as those with other complex medical problems
(ex. former premature infants with multiple medical and social needs, children with
complex congenital heart disease, patients with genetic syndromes requiring
multidisciplinary care etc.). This allows us to be sure each of our residents provide
longitudinal primary care to this growing population of children and adolescents and
understand the true value of caring for CSHCN.
Healthy Futures Education Programs: Screening, Tutoring and Career Counseling
Poor school performance and school failure are linked to a number of poor health
outcomes and youth risk behavior. Conversely, physical and mental health issues and
risk behavior impede learning, employment and self sufficiency. Although services exist
to address these issues, they are often fragmented and difficult to access. Pediatric
primary care offers an opportunity to promote school performance and transition to
college or work. The HLC screens for developmental and learning delays and offers
guidance on evaluation of learning disabilities. The providers also screen for issues
related to transition from pediatric to adult care and self sufficiency. We participate in
the Reach Out and Read Program handing out books to patients and encouraging family
reading and have an Adolescent Literacy Program. Since 2008 the HLC has had an onsite tutoring program for elementary school age children and a career counseling
program for older children and adolescents. Our goal is to increase the number of
youth who are on grade level and complete high school, pursue post-secondary
education, attain employment, avoid drugs, alcohol, and violence and ultimately achieve
economic self sufficiency through educational support, training and workforce
programs. These programs have served hundreds of families in providing resources and
guidance for healthy futures.
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