When Natalie Boyle was undergoing treatment for cancer, she was able to rely on family who lived near her home in Dallas, Texas, and afford to hire a nanny to help care for her 18-month-old twin daughters.
But when her friend Annie was diagnosed with colon cancer, she told Boyle that she couldn't afford to hire someone to look after her two kids, ages 2 and 4. Her mother was looking after the kids, but she didn't live nearby and couldn't stay any longer. Annie wanted to ask a friend to look after the kids on treatment days and herself the other days, but Boyle wanted to make sure she had more consistent support.
Boyle mobilized her social network and used online crowdfunding to raise money to hire a nanny for Annie's family. Over time, more and more people saw her crowdfunding efforts online and began asking for child care assistance for friends and neighbors facing the health crisis.
“I joke that I started a nonprofit by accident,” Boyle says.
As the organization grew, the overwhelming demand for child care for sick caregivers became more apparent. While in-home nannies worked for many, they were hard to scale and couldn't meet the needs of many families, especially low-income ones. Boyle wanted to provide an option that was accessible to everyone who needed child care while receiving medical care.
So she reached out to Kavita Bhavan, MD, MHS, chief innovation officer at Parkland Health in Dallas, Texas, who works to develop novel solutions to health system challenges. Boyle's idea was to open a free childcare center within the hospital for patients.
“The moment I met her I thought, 'This is really revolutionary,'” Bavan said. “It's basically a reverse Ronald McDonald House — a safe place for kids to stay while, say, a parent is undergoing cancer treatment.”
In 2020, Parkland researchers surveyed female patients of reproductive age and found that more than half reported missing medical care due to a lack of child care. Lack of child care was the top reason for missing routine checkups or appointments to address medical issues, followed by lack of transportation and insurance, according to the survey.
A few months later, in November 2020, Annie's Place opened in Parkland, named after a friend of Boyle's who died of cancer while preparing to open the center. Since then, Annie's Place has cared for more than 2,000 children at no cost to their families.
“This has enabled parents to attend thousands of medical appointments,” Boyle said, “and we know from experience that this saves lives.”
It's an approach that few hospitals have adopted, but Bhavan believes it's at the cutting edge of a growing movement to address the social determinants of health.
While there have been many health system interventions aimed at other non-medical barriers to health, such as housing, nutrition and transportation, the discussion around child care has been slow to develop, Bhavan said.
More than a decade ago, the U.S. Department of Veterans Affairs (VA) launched a pilot program to offer free child care at three VA medical centers across the country, citing survey results that showed one-third of veterans were interested in child care services and 10% had canceled or rescheduled VA medical appointments due to a lack of child care. Currently, only one center is running the program, but the department plans to expand it to VA facilities across the country, according to spokesman Terrance Hayes.
Additionally, the COVID-19 pandemic has revealed the negative impact that a lack of reliable child care for healthcare workers has on a functioning healthcare system. According to a 2022 KFF Health News article, some hospitals have recognized this as a leading cause of healthcare worker absenteeism and disengagement from the healthcare workforce and are ramping up their child care offerings to increase retention.
“we, [lack of childcare] “This is a much more universal issue,” Bhavan said.
Building a framework
Bavan and other Parkland leaders were enthusiastic about the prospect of free, on-site child care but recognized that launching such a program would be logistically challenging.
“It's rare to see a program like this in a health system, let alone a large teaching hospital,” Bavan said. “It's a huge undertaking to build community-based partnerships.”
But with the support of health system administrators, Boyle's organization, and philanthropic foundations, the hospital identified a building on campus and renovated it to create an inviting, stimulating environment for young children. Health system leaders worked with Boyle's team to establish a licensed child care center and hire qualified staff, including bilingual staff, to accommodate the large Spanish-speaking population the hospital serves.
Bavan and her team focused on coordinating the logistics on the health system side, including arranging shuttle buses from the child care center to other locations on campus, setting up a referral system for health care providers, making sure all communications comply with health care privacy laws, and establishing metrics and dashboards to monitor progress. Researchers from Parkland Health and University of Texas Southwestern Medical Center are studying the data collected, and initial findings have been accepted for publication in BMC Public Health, an open-access, peer-reviewed journal, Bavan says.
So far, Bavan has been encouraged by the community's response. She's heard many success stories: a mother who gave birth to premature twins and left one of them at Annie's Place while the other bonded in the neonatal intensive care unit; a mother who received her first prenatal care at seven months pregnant, when her other baby had a safe place to stay while she was being examined; and a mother who was finally able to schedule surgery to remove a tumor.
These cases show that addressing patients' basic needs can benefit both patients and healthcare providers by saving the health care system money and potentially improving long-term health outcomes, Bhavan said.
“Every time I had to cancel a surgery, my health got worse. [operating room]”That's a lot of money,” she says. “Addressing the social determinants of health related to child care helps improve the process and quality of care.”
The VA also recognizes the potential value of providing free child care to parents receiving care. A 2015 agency report examining barriers to accessing VA care for female veterans cited lack of child care as a major barrier, with more than 60 percent of women surveyed saying they would benefit from on-site child care. Currently, only the American Lake VA Medical Center in Tacoma, Washington, offers the service, but officials say other facilities will expand it in the future.
“VA is actively working to implement child care support services for eligible veterans who are enrolled in VA health care and have eligible VA appointments,” Hayes said in a statement to AAMC News. “VA plans to expand these services to other VA facilities across the country and is developing a reimbursement system for drop-in child care services provided in the community during a veteran's eligible VA appointment.”
Since opening, Annie's Place has expanded its services to serve any parent in need of childcare, whether that be for preventative checkups and treatments, responding to medical emergencies, or caring for other children while siblings are attending medical appointments. It also provides backup childcare on weekends for hospital staff.
Because Parkland serves a population that is largely uninsured and living well below the poverty level, Bavan hopes that by giving more patients access to preventive care and consistent treatment for illnesses, it could make a difference in reducing health inequities.
“We are currently looking at clinical health outcomes to evaluate the impact of Annie's Place and address the child care needs of our residents,” Bhavan said.
Support for healthcare workers
Helping patients show up for their appointments is one thing, but making sure they are being seen by a healthcare professional who can help them receive quality care is also key.
An analysis published in the journal Health Affairs found that 100,000 registered nurses will leave the nursing profession in 2021, with a variety of factors contributing to the decline, including retirement, burnout, and lack of child care, the authors wrote. In 2023, AAMCNews reported that several teaching hospitals believe the nursing shortage, exacerbated by the pandemic, is now at crisis levels. And the American Association of Colleges of Nursing points to research showing that fewer nurses working leads to worse patient outcomes, including higher readmission and infection rates and higher patient mortality rates.
In August 2022, KFF Health News reported that some hospitals are offering child care services as a way to retain nurses and other hospital staff. Bright Horizons, a national child care center operator, has partnered with dozens of hospitals to provide on-site child care for their employees. According to a survey of nurses commissioned by Bright Horizons in 2017, 70% of respondents said they had missed a shift in the past six months because their child was sick or they couldn't find child care.
According to a 2024 Nursing Solutions report, the national average hospital turnover rate is 20 percent, and turnover costs hospitals an average of $56,300 per bedside nurse, meaning the average hospital loses $3.9 million to $5.8 million annually in nurse turnover costs. A 1 percent decrease in turnover rate could save hospitals $262,500 annually, the report states. One business analysis by the Boston Consulting Group found that companies across various industries that offer child care benefits could achieve a return on investment of up to 425 percent.
One hospital featured in a KFF Health News article reported that 91% of employees who sent their children to on-site daycare said in a survey that it was their main reason for staying on the job.
Change the conversation
Boyle said leaders of health systems across the country have contacted her about starting an Annie's Place on their campuses.
“We can't run 1,000 child care centers, but we're looking for ways to share our knowledge on how to run them,” Boyle says. Annie's Place is already expanding: The Parkland facility is undergoing renovations that will double its size to meet growing demand for its services, but it will remain open during the renovations.
Bhavan encourages leaders of other academic health systems to collaborate with local organizations that have expertise in child care and build partnerships that can grow into mutually beneficial services.
“Our strength is healthcare, and being a community-based organization [like Annie’s Place] “I specialize in child care,” she says.
As Parkland researchers continue to collect data to measure the program's effectiveness, Bavan and Boyle hope their study will draw attention to the importance of child care in medical settings.
“When we talk about social determinants of health, most charts don't include child or dependent care,” Boyle said. “We [for it to be included, because] “This is as big a barrier as a lot of other things that people think about, like transportation or stable housing. Providing child care can save lives.”
