UMC clinic helps children and families navigate foster care

By Amelia Neumeister

As a foster parent, Dr. Brian Gannon knows that children and families in foster care can face challenges navigating medical care, paperwork, state agencies, schools and other aspects of case management. He has eight children—six of which were adopted. And four of those adoptions were through foster placements.

Physicians can legally request information on foster children, says Gannon, a pediatrician at University Medical Center, which is operated by The University of Alabama College of Community Health Sciences. So he wanted to streamline the flow of information, help to gather all of a foster child’s relevant information in one place and provide them access to health care and resources. To do that, he started the FRESH Start Clinic at UMC.

FRESH stands for Fostering Resilience through Education, Support and Healthy choices. Since opening its doors in July 2016 at UMC, the FRESH Start Clinic provides care for children in foster care and for families and professionals who support them. The clinic is held on Thursday afternoons.

The goal of the clinic is to advocate for the specialized needs of children in foster care and to change the way children in foster care are obtaining medical care, says Gannon.

He and his team of nurses, a receptionist and social work students wanted to create a clinic for foster children based off the Patient-Centered Medical Home, a model of health care that is patient-centered, accessible, continuous, comprehensive and coordinated, and that focuses on quality and safety.

The clinic works in partnership with the Tuscaloosa County Department of Human Resources, and includes all members of the foster child’s team in health care decisions as appropriate, including the foster parents, birth parents, DHR caseworkers and investigators, noncustodial family members, residential home staff and mental health providers.

“There are different [foster care clinic] models across the country,” says Gannon. “A lot of the larger cities will have foster care clinics that are much more involved than what we are starting right now. We’d like to work into that. The goal would be to have mental health, development and social work all on-site as part of the process, because these kids are known to have more needs than your average pediatric population.”

Gannon had the idea for the FRESH Start Clinic after studying similar clinics in urban areas where foster care is more commonly found, he says. By partnering with UMC, he hopes the clinic can serve as a state-wide model and can bring access to rural areas where foster homes are less common.

Gannon says he drew from his experiences as a both a doctor and a foster parent to help plan the clinic.

“There are so many little things that make it difficult as a foster parent to get the care   that the child needs,” he says. “So, my goal was to make all that easier.”

Foster parents can call to set up an appointment in the clinic as soon as the child is placed in their care, Gannon says. They can be seen within a week. At the first visit, the child’s medical, social and psychiatric history will be collected and requests will be submitted for any  additional records needed. Gathering this information helps to streamlines the process of medical care for children in the foster system, Gannon says.

Once additional records are obtained, another visit will be scheduled. The clinic will assess the child’s adjustment to his or her foster placement and will look into any behavioral concerns a foster parent might have. A trauma assessment will also be performed to help families address needs of children who have suffered from abuse or neglect.

From there, the FRESH Start Clinic can provide primary care for children in state custody or can serve as a consultant to their chosen doctor. The clinic also stays in touch with DHR and is notified of any changes in the child’s placement or goals.

The FRESH Start Clinic knows how to gather background information and navigate paperwork that many foster parents simply don’t have time for, Gannon says. If the parents are not dealing with paperwork, they will have less difficulty making appointments, he says.

“I’ve gotten a lot of positive feedback from the foster parents that I’ve worked with as well as the caseworkers, because the DHR caseworkers will have dozens of children on their caseload,” Gannon says. “Often they’ve had more negative experiences than foster parents have as far as interacting with doctors’ offices and things being challenging and not running smoothly, and they’ve been very pleased with the efficiency that we’ve been able to provide to them.”

The long-term goal for the clinic is to create an infrastructure to bring the clinic to a wider audience.

“I would love for this to be a model for the state and have interested doctors all over the state who have extra training and special interests,” he says. “And we could have case managers that make sure all these children get what they need. I think over time that would be a really good goal. But we are starting small—starting with one county.”

Mini Medical School Topics: Women’s Health, Injury Prevention and Telemedicine

Breast cancer is the second leading cause of death among women, so prevention and screening are important, not only for breast cancer but also for other gynecologic cancers, according to Dr. Kristie Graettinger, a physician in Obstetrics and Gynecology at University Medical Center.

Graettinger provided a presentation, “Women’s Health Update: Cancer Prevention,” at the Oct. 20 Mini Medical School program conducted in collaboration with UA’s OLLI program.

In addition to her presentation, three other faculty members presented during the month of October. Dr. Ray Stewart, a physician in Sports Medicine at UMC, talked about “Preventing Injury” on Oct. 6, and Dr. Karen Burgess, a pediatrician at UMC, gave a presentation on “Telemedicine” on Oct. 13.

Mini Medical School lets adults and community learners explore trends in medicine and health, and the lectures by UMC providers give information about issues and advances in medicine and research. OLLI, short for Osher Lifelong Learning Institute, is a member-led program catering to those aged 50 years and older and offers education courses as well as field trips, socials, special events and travel.

In her presentation, Graettinger said to think of cancer prevention as three tiers: “prevention, screening and treatment.” Prevention is interventions to reduce the risk of cancer, including maintaining a healthy weight, being physically active, having a diet high in fruits, vegetables and whole grains and low in processed foods and red meats, and receiving vaccinations that can protect against cancer, such as the HPV vaccine for cervical cancer. Examples of screening include mammograms for breast cancer and pap smears for cervical cancer.

“The goal is first to try and prevent cancer, and also to identify people at risk for the disease,” Graettinger said.

Breast cancer is the second leading cause of death among women, right behind lung cancer, and will affect 1 in 8 women in their lifetimes. Approximately 250,000 cases of breast cancer are diagnosed every year.

Having a first-degree relative, such as a mother or sister, with breast cancer doubles the risk, but that amounts to only 15 percent of women diagnosed. Breast cancer screening includes mammograms, clinical exams performed by a physician or health professional, breast self-exams and genetic testing.

A mammogram is an x-ray of the breast. Currently there is not a consensus among organizations about the age a woman without a family history of breast cancer should be – ranging from 40 to 50 – to begin receiving annual mammograms.

There is recent evidence that clinical breast exams might not be helpful for women without symptoms of breast cancer, “but have that discussion with your doctor,” Graettinger said. She added that the concept of breast self-exams has shifted to “being aware of your breasts.”

For women with the inherited BRCA gene mutation, “this is serious business and increases the risk of breast cancer from 1 in 8 to 1 in 2, or by 50 percent, and the risk of ovarian cancer is 10 times greater,” Graettinger said. Having the BRCA gene is “not extremely common, but it’s not rare,” she said, adding that women with a personal history of breast cancer should consult with their physicians about this genetic testing.

Other gynecologic cancers include cervical, ovarian and uterine cancer. Of those, only cervical cancer has a screening test – pap smears, which detect precancerous changes on the cervix. Pap smears are now recommended every three years for women ages 21 to 65.

Ovarian and uterine cancers are detected by signs and symptoms, “which is scary because sometimes these are found in the later stages,” Graettinger said. Symptoms of ovarian cancer are vague and include pelvic and abdominal pain and pressure, bloating and feeling full quickly, and irregular bleeding. Approximately 20,000 cases of ovarian cancer are diagnosed annually. Pressure, pain and bleeding after menopause are common symptoms of uterine cancer, which primarily strikes women over the age of 50.
In Stewart’s presentation, he said that “sprains and strains are where the vast majority of injuries are occurring.” The most common sports injury is an ankle sprain, followed by a groin sprain and a hamstring sprain.

Stewart said the goal is to introduce preventive measures to avoid the injury. A warm up is a good way to do that. A warm up should get the body moving, introduce a light sweat and “literally warm up the muscles,” he said.

Stretching is a good way to prevent injuries, too. There is dynamic stretching, which are bouncing, jerking movements, static stretching, which are slow, deliberate movements that are held for about 20 seconds, and then proprioceptive neuromuscular facilitation, or PNF stretching, which combines static stretching with isometric movements to increase flexibility.

To prevent an ankle sprain, Stewart suggested wearing an ankle support to reduce the risk and to conduct balance training: stand on one leg in order to train muscles to support the ankle.

To prevent a hamstring sprain, Nordic hamstring exercises are best, Stewart said.

There is a higher injury rate of the ACL in women, and prevention requires regular exercises. Plyometrics, known as “jump training” help may reduce an ACL injury, but must be performed throughout the athlete’s season. After the participant stops performing the training exercises, he or she becomes at risk for injury again.
Burgess introduced many of participants in the Mini Medical School series to the concept of telemedicine for the first time.

Telemedicine is any medical information exchanged from one site to another through the use of technology. It could be a phone or computer.

“We use it to improve access to care,” said Burgess.

Many parts of Alabama are rural and are underserved in primary care and specialty care providers. Unfortunately, many of the underserved areas in Alabama are also areas with limited connectivity, which makes it difficult to access telemedicine, Burgess said.

Burgess spoke about Telemedicine and Telehealth efforts at the UA College of Community Health Sciences, which operates UMC, including the asthma education program that she and Beth Smith, a nurse practitioner in pediatrics at UMC, have led. Students at Greensboro Elementary School in Hale County and their parents are taught through telemedicine about asthma symptoms, medication and treatment. The program teaches  students how to use a spacer with their asthma inhaler for more effective usage of their medicine.

The program so far has revealed that students and parents are learning more about asthma and how to treat it.

One participant said: “Until today I had no idea what telemedicine was. Thank you for coming here and telling us about that today.”

Mini Medical School topics include ADHD in grandchildren, geriatric depression and parkinsonism

The University of Alabama College of Community Health Sciences, which operates University Medical Center, hosted its second semester of Mini Medical School, a lecture series for UA’s OLLI program put on by UMC providers. The series is open to the public.

Mini Medical School lets adults and community  learners explore trends in medicine and health, and the lectures by UMC providers give information about issues and advances in medicine and research. OLLI, short for Osher Lifelong Learning Institute, is a member-led program catering to those aged 50 years and older and offers education courses as well as field trips, socials, special events and travel.

Parkinsonism — Dr. Catherine Ikard

Many people think of Parkinson’s disease as a single disorder, but it is actually more complicated than that, said Dr. Catherine Ikard, a neurologist at UMC.

Parkinsonism is a syndrome characterized by decreased movement and is associated with tremors and a loss of balance, Ikard said at her lecture, titled “Parkinsonism and Parkinson’s Disease,” which she presented as part of the Mini Medical School series on Sept. 15.

Parkinsonism can appear in an array of disorders, some even as a result of repeated head trauma or medication, but the most common one—the one most people refer to when they think of Parkinson’s Disease—is Idiopathic Parkinson’s Disease.

Idiopathic Parkinson’s Disease is the progressive loss of dopamine-producing cells in the brain. The disease is slow and degenerative. “We don’t know why this happens,” Ikard said.

There are motor symptoms, which include shaking, smaller and slower movements, becoming stiff and losing balance more easily. Motor symptoms usually start on one side of the body. Tremors can worsen when the patient is at rest, and they are suppressible by concentration.

Non-motor symptoms include affective disorders, such as depression, orthostatic hypotension (when blood pressure falls significantly when standing up too quickly), memory impairment, fatigue, constipation and sleep disturbances.

There is no test for Idiopathic Parkinson’s Disease, Ikard said. The diagnosis is clinical. “We often have to watch a tremor over time—months, sometimes years,” Ikard said.

Medication and therapy can help treat symptoms, Ikard said. The most common medication is Levodopa, and physical and speech therapy can help improve lifestyle. “I cannot emphasize enough how important therapy is for patients with Parkinsonism,” said Ikard. Exercise improves symptoms, too, she said.

There are clues that the disorder might not be traditional Idiopathic Parkinson’s Disease, Ikard said.

Some of these include: rapid progression of the disease, absence of tremors, frequent falls early in the disease, abnormal eye movement and poor response to Levodopa. If that is the case, the Parkinsonism could be tied to another disorder.

Grandchildren and ADHD — Dr. Brian Gannon

Children are very active from the ages of 2 to 5, but that busyness should decrease over time, said Dr. Brian Gannon, a pediatrician at UMC.

But as children get older and if they are easily distracted, can’t stick with a task for a reasonable amount of time and their activity level is not appropriate for their age, they could suffer from ADHD, or attention deficit hyperactivity disorder.

“ADHD is defined as an activity level that is inappropriate for age, that interferes with school work, that causes trouble in dealing with adults,” Gannon said during a lecture on Sept. 22, titled “Grandparents and ADHD.”

Gannon said about 5 percent of the general population in the US qualifies for an ADHD diagnosis. He said sometimes the markers of what appears to be ADHD are actually caused by other medical issues. He said hearing, vision and speech problems can cause some of the same symptoms of ADHD, as can developmental delays, autism and sensory processing disorder.

“We want to look at medical issues because they may cause similar issues to ADHD,” Gannon said.

A child’s living situation – unstable home environment, varying and inconsistent rules and food insecurity – is also a factor. “My job as a physician is to advocate for the child and help parents problem solve. We don’t want to just throw medicine at a child.”

Gannon said medication can help and should be part of efforts to manage ADHD, but is only part of the answer. “Children still need to follow the rules, and do their work. With medication, they can do it without your help.”

Geriatric Depression — Dr. John Burkhardt

Older adults are at risk for depression. One reason: The more medical burdens one has, the higher the risk of depression, said Dr. John Burkhardt, a clinical psychologist with UMC-Northport.

“Chronic pain conditions can be managed, but you never get a break from them. Heart problems can precipitate depressive episodes, and then you have to eat differently, go to physical therapy and deal with a chronic condition. What does that do to your mood?” said Burkhardt, also an assistant professor of Psychiatry and Behavioral medicine for UA’s College of Community Health Sciences, which operates UMC-Northport.

His remarks came in a lecture titled “Geriatric Depression” that he provided on Sept. 29 as part of the Mini Medical School lecture series.

Burkhardt said changes in previous functioning, pain and sleep disruption, significant weight gain or loss, a loss of interest in activities, a sad and depressed mood, a feeling of being a burden – and if those conditions and feelings go on for two weeks or more – could signal possible depression. “A lot of people go through sad times. But when it starts to impact your functioning, that could be depression.”

With older couples, depression can also be “contagious,” Burkhardt said. “If one spouse is depressed, the other spouse is at an increased risk of depression.”

Late-life depression, which happens after the age of 60, can carry added risk because it can transition to dementia, Burkhardt said.

He stressed that depression needs to be treated, particularly in the elderly, who might not seek care because of an associated perceived stigma. He noted that suicide is the 17th leading cause of death in those aged 65 and older.

“When you’re depressed, you’re not good at coping with your physical conditions. Depression impacts the person who is experiencing it, and their families. Who wants to visit people when they aren’t happy? Then they’re alone.”

Burkhardt recommended that people watch for changes in behavior, thoughts, appetite, sleep and whether they lose interest in activities once important to them. “See a provider if you suspect depression. Don’t let stigma keep you from getting help. Don’t isolate yourself. Be social, stay active and have a daily structure.”

UA Matters: Helping Children Connect with Nature

Spending time in nature improves mood, reduces stress and promotes better physical health. Despite the countless benefits, it has become increasingly difficult to separate ourselves from our busy schedules, electronic devices and creature comforts to spend time outside.

Helping children connect with nature is critically important, experts say. In addition to the health benefits, spending time together outside can promote stronger parent-child attachments, teach children that natural resources are not limitless and inspire them to protect our environment.

The University of Alabama’s Dr. Caroline Boxmeyer offers some ideas that may help.

All About Baby Growth Spurts

Dr. Brian Gannon, a physician in Pediatrics at University Medical Center, says there are ways to tell if your baby is going through a burst of growth and offers tips for making it through.