Glasses and Good Nurses

Before a child can learn, they need to be able to see. And before a nurse can care for a complex pediatric patient, they need to have experienced something close to it. In this episode, two leaders at the intersection of innovation and workforce development share how they are closing two very different but equally foundational gaps.

Dr. James Dickhoner, Chief Medical Officer of Vision to Learn and Associate Director of Digital Health at CHLA, describes how a mobile clinic model is providing free eye exams and glasses to between two and four million children across the United States who need vision correction and can't get it, and the surprisingly apolitical case for why every school district should want this.

Dr. Jennifer Baird, Associate Chief Nursing Officer for Professional Practice at CHLA, shares how the Pediatric Pathway Program is transforming how nursing students experience pediatric care, tripling and quadrupling clinical hours in pediatric settings, integrating simulation, and sending nurses into the workforce with a depth of preparation that the traditional generalist model simply doesn't provide.

Episode Resources:

Pediatric Pathway Program CHLA

RN Residency in Pediatrics CHLA

Las Madrinas Simulation Center CHLA

Eyeglasses for School Kids Boost Academic Performance, Study Finds

Dr. Megan Collins - Johns Hopkins School of Medicine

Gifts You Can Give That Save Lives

Effect of a Randomized Interventional School-Based Vision Program on Academic Performance of Students in Grades 3 to 7 - A Cluster Randomized Clinical Trial

Vision To Learn DONATE

Connect with Dr. James Dickhoner:

James Dickhoner LinkedIn

James Dickhoner CHLA

Vision To Learn Website

Vision To Learn LinkedIn

Vision To Learn Instagram

Vision To Learn DONATE

Connect with Dr. Jennifer Baird:

Dr. Jennifer Baird LinkedIn

Dr. Jennifer Baird CHLA

Connect with us:

KidsX Website

KidsX LinkedIn

Children's Hospital L.A. Website

Children's Hospital L.A. Instagram

Children's Hospital L.A. LinkedIn

Transcript

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SPEAKER_02 0:01

Welcome to the Dose of Optimism, where I talk to the optimists in healthcare. My name is Omkar Kulkarni, and I work at one of the world's best children's hospitals where I lead innovation. I started KidsX, which is a premier international startup accelerator for pediatric innovation, and over the years I've met thousands of startups, investors, and innovators. Every one of them has a story, and every one of them is optimistic about the problems they're solving. On this podcast, you'll meet amazing people who will share their stories and what makes them optimistic about the future of healthcare. We are not offering medical advice and we're not endorsing any products. Please talk to your own physician about your health or the health of your children. All right, let's get started.

SPEAKER_01 0:55

Vision to learn exists because students need to be able to see the blackboard. And so to do that, we provide soup to nuts eye care, refractive eye care for school, yeah, school-aged kids that really don't have any other option to get glasses. So we do that through mobile clinics. We go through, we screen kids. We do about 500,000 screenings a year. About 120,000 of those kids end up needing eye exams. And so we come back two to four weeks later with a mobile clinic with an optometrist, fully kitted out, provide comprehensive eye exams. And then 85 to 90% of those kids end up needing glasses. The other 10% either don't need additional care or they need to be seen by a community provider. And so we come back three to four weeks later and give glasses. And so this past school year, we gave out just over 100,000 pairs of glasses.

SPEAKER_02 1:50

You're describing a world where there are lots of kids around this country who, despite having access to a pediatrician, are just not getting their eyes checked.

SPEAKER_01 2:00

Yep. Yeah. The US kind of treats vision care, particularly refractive vision care, like glasses as a sidecar, like dental, where it's not really fully wrapped up in our healthcare system. From a federal level, Medicaid does provide vision benefits for children under 18.

unknown 2:17

Okay.

SPEAKER_02 2:18

But still, we're finding that kids are not accessing those services, those benefits in some way. And so they're showing it to school, many of whom aren't able to see the board, they're not able to learn as well as they could.

SPEAKER_01 2:32

That's entirely right. It's kind of a debated topic within this little small community of school-based vision providers on what is the actual unmet need. I was at a set of meetings in New York last week and anecdotally asking people what they thought that number was. And the low end is 2 million, the high end is 4 million. Kids that need glasses are currently aren't getting them. The vast majority of that is an access barrier. They don't know how to use their benefit, or they can't find a provider who will take their benefit because, like anywhere in pediatrics, the Medicaid reimbursement rates are below probably what it costs to provide the service. And so there's not a ton of supply of optometrists who take Medicaid at a scale that's necessary to address that two to four million number.

SPEAKER_02 3:18

So in your model, is it the school that does the initial screening, or do you guys do that?

SPEAKER_01 3:24

It depends. So we depends on the state. So Vision to Learn, we're in 15 states currently. We'll be in 18 this school year. The vast majority of the screens we do ourselves, but we do have some long-standing kind of community partnerships where they provide that screening. And then lots of states, I think it's 37 states maybe, have compulsory eye screening. In general, not categorically, but in general, we don't use those results to determine whether a kid needs an eye exam or not. And in general, we're not trying to replicate the state-mandated screening exams.

SPEAKER_02 4:00

Are there apps that are available for parents who they can use just as a even a pre-screening or something to figure out if their kids are having trouble? I imagine some of this can be replicated using basic technology.

SPEAKER_01 4:16

Yeah. Um, I was just reading a paper this morning about a small trial they did during just post-COVID on at-home visual acuity screening. And their results show that they were within one line of kind of the gold standard Snell and chart. They found that true. I think they did three different methods, but the two that come to mind, one was an app-based tool, and then the other was just a paper chart that they sent home with instructions. So there definitely is, and visual acuity is relatively easy to test. Everybody's been through cover your right eye, cover your left eye. You can tell if you're reading the letters appropriately. They can get much more complex when you start looking for other issues, but that straight visual acuity you can certainly test at home with an app.

SPEAKER_02 4:58

So you guys are in 15 states, and is this mostly urban centers?

SPEAKER_01 5:03

I don't have a good breakdown exactly on what are our percentages. Anecdotally, I would bet that 80% are urban centers, just based on where our biggest programs are, which are in Philly and Los Angeles and Atlanta. But we definitely do rural care. And rural care is challenging, right? When you start distributing how far you have to drive all of that, our vans are expensive. They're cost a lot of money. If you have an optometrist that's traveling two hours each way, that gets expensive as well. With that said, given the current kind of policy in the US, there's a ton of money flowing into rural health care. And our program's kind of uniquely suited to be an option for those states that have tens, if not hundreds, of millions of dollars to spend. And so we've seen a big uptake, and we don't know how it's going to play out. It's over the next couple of months. Either it could be three, four, or five states that are bringing vision to learn in with that funding.

SPEAKER_02 5:59

And so you're funded, I imagine, with a hybrid of funding sources, philanthropy, and build Medicaid.

SPEAKER_01 6:07

We do. So I think as of last week, Medicaid now is the biggest funder of Vision to Learn historically since we started. We generally, our general mental models, about a third of it comes from public sources, which is Medicaid, Chip HSI. Those are our two kind of primary drivers there. There are some smaller kind of grants from cities and health departments that fund some of our local services. A third comes from donor base, and then a third from corporate philanthropic type sources, although that that ratio is directionally accurate.

SPEAKER_02 6:43

Your name indicates that vision's key to learning, it's intuitive. Have you done any studies or shown any improvements in academic performance that's on the other red?

SPEAKER_01 6:55

Yeah. So there's a study that we often refer to that is published out of Hopkins, who's been a long-term partner. Dr. Megan Collins has been a big supporter of Vision to Learn for a long time. And so they did a study, and I believe the benefit that the way they quantified it was it's an equal to six months of additional learning if you get a kid wearing glasses for two years. In terms of bang for your buck, the alternatives might be after school tutoring, individualized lesson plans, things like that. Eye care is really compelling from an investment case.

SPEAKER_02 7:31

Based on CDC data, it seems like about a quarter of elementary school age kids need vision correction and 40 to 50 percent of middle and high school kids need it, whether they get have have access to and actually wear glasses or contacts.

SPEAKER_01 7:46

Yeah, and it's the the prevalence of myopia is increasing, right? So kids need glasses, more kids need glasses than ever. Yeah, there's different theories on it. I think the most commonly accepted explanation is screen time. When your eyes developing, you spend time focusing at a faraway point, it's healthier for your eye. It's getting your newborn out and letting them look at trees, getting kids to play outside, all of that. There's a belief that that decreases uh the need for glasses. But I don't know if that's substantiated. But we're definitely seeing increases, and yeah, our numbers, what's 30% plus of the population that we work with, regardless of kind of age, and you do see an increase, particularly kind of that high school, which makes sense. It aligns with when kids are going through that development phase, and then your eyes change just like their bodies do.

SPEAKER_02 8:34

So you paint a completely obvious reason for why this needs to be everywhere, but it's not. So what is what makes it so hard? What are the hard parts about getting this kind of model off the ground?

SPEAKER_01 8:44

Yeah. So there's one kind of central clinical question, and I think it's a classic resource allocation question, which is what should standard of care be? And specifically in this context is should individuals getting their first eye exam be dilated? Generally accepted, best practice is that you want to dilate so you can see the full back of the retina. It also allows you, particularly in younger kids, to get a better prescription because you can paralyze the eye muscles. And so I don't think anybody disputes that's the ideal. The challenge with that is it takes more resources, right? And schools are hesitant to allow you to dilate it on site. So that's a big piece. The next one is around consents. And so that's a very state-by-state kind of driven conversation. And states that have strong parental rights will require us to do opt-in consent, meaning that the parent has to positively affirm that they want their child screened and then examined. Other states take a approach where they allow opt-out consent. And so we'll go from we're in an opt-in state, maybe 30% of students receiving coverage or less to 90% plus if it's opt-out. The other barrier that we think about is workforce. So I was just talking with a doctor from New England College of Optometry who does a lot of work workforce research. And he was looking at the retiring doctors versus the new ones entering the workforce. And he was saying that the retiring doctors work about a 1.2 FTE equivalent. The new doctors entering work 0.7 to 0.8. And so our total capacity for optometry across the board is either neutral or decreasing with our population expanding. And so you get into that kind of wicked type problem where there's just not enough eye care providers to be able to appropriately treat this group. And so if you believe, which I do, the ability to see the board really shouldn't be viewed as a medical problem. It's really something that needs to be viewed as every every student deserves that, right? You're not going to be successful in school. You're going to struggle if you can't see the board. And so if you think about that workforce challenge, you have to come up with a way to more efficiently use your limited optometrists. Um so there are some kind of global health approaches with instrument-based screening that you could use. Certainly, if you do mandate dilation, that's going to decrease your ability to provide those exams. But that's kind of the crux of the challenge for us.

SPEAKER_02 11:08

Schools are also incentivized, not only from an attendance standpoint, but a performance standpoint. If the kids perform better in schools, in many cases, there's advantages to schools financially and otherwise. So you could see a world where from a school district standpoint, they'd be motivated to get all their kids able to see, not only because it's a basic educated right, but it's also beneficial to them to make sure they're students performing it at all.

SPEAKER_01 11:32

You know, I view it as kind of the free lunch, right? If the kids are hungry, they're not going to be able to focus. Yep. Can't see the blackbird, they're not going to be able to learn. And I want to see the country adopt that point of view, right? And then with that, if you really adopt that, then start thinking about how do you fund it. Right now, when you work in the Medicaid space, is there an opportunity to think about school-based healthcare codes or have a different funding mechanism where you can get glasses on the faces of kids that need them, but not try to fill the full vision care gap, which is necessary, but by trying to fill that full gap, it just makes it really difficult to reach those two to four million kids that need that care.

SPEAKER_02 12:11

So as you look for the next year to three years, what are you most excited about for vision to learn?

SPEAKER_01 12:16

The thing that I'm most excited about is when I took on this role, I'm the first chief medical officer at Vision to Learn. I'm not an eye doctor. And so I come with kind of a systems and a development background. I have great optometrists that work for me. They're the ones that are really driving our clinical protocol forward. And so that frees me up to look at how do we get more efficient? How do we start addressing it? And like I took the job, and my mission while I'm at Vision2Learn is to figure out how to get those two to four million kids to glasses they need. And so Vision to Learn is really fortunate in that it's a really compelling, simple mission that really resonates with different funders and it resonates across the political spectrum. And so we have the opportunity to be innovative. We're also at a scale now where we can start sitting down. We do this, right? We sat down with the governor of Ohio and they're the first statewide school-based vision program, Ohio C. And so we can work on a policy level that most small providers working in the space can't. And then I'm able to spend my time trying to figure out how to be more efficient, how to provide a higher quality exam with less resources. And I think over the next two to three years, I think there's some real opportunity and care model innovation that could dramatically lower the cost.

SPEAKER_02 13:33

So it seems like you're in over 850 cities in California, Connecticut, Delaware, Georgia, Hawaii, Iowa, Louisiana, Maryland, Michigan, Mississippi, New Jersey, North Carolina, Ohio, like you said, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and DC. Is that right? Some of that's a little bit fluid. We'll be in Florida this year, we'll be in Wisconsin this year. It's a really diverse array. I guess my point is very different parts of the country represented for sure. Geographically, I imagine, politically, lots of things going on. And it seems like you guys have reached a a wide range of places.

SPEAKER_01 14:11

It's one of those things that, first of all, we don't get a whole lot of resistance to eyeglasses, right? It's not like the controversy around whether to wear a mask or vaccine or whatever. People just accept eyeglasses as a thing that people need. And so there's not a culture component to it that we're trying to overcome. And then when it comes to kind of your arguments, it's the service model is the same. What we provide is the same, but you can frame it very quickly as this does an economic benefit, right? It helped it's helping people achieve what they their best possible self. Or you can say, hey, this is an equity argument, right? Every student should be able to access this type of care. And whichever resonates, we provide the same service. And so I think we're really fortunate in that. And then the other piece is it's almost inarguable, right? Kids need glasses to be able to see the board. They do better if they can. We can go through the data and look at studies and all of that, but like everybody instinctively agrees with that. I've yet to meet somebody who says, no, that's not true. So we really benefit from that clarity.

SPEAKER_02 15:12

That's awesome. James, thanks for joining us and all the awesome work you're doing. And now a thank you to our generous sponsors. Great technology doesn't just make work faster, it helps people do their best work. That's why Nobla is building the clinical AI layer supporting clinicians across every patient encounter so every interaction can feel a little more human. Learn more at Nobla.com. Jenny, how are you?

SPEAKER_00 15:42

I'm good.

SPEAKER_02 15:43

Thank you for joining us.

SPEAKER_00 15:44

Oh, thanks. Glad to be here.

SPEAKER_02 15:46

Tell me what you do.

SPEAKER_00 15:48

I am the Associate Chief Nursing Officer for Professional Practice at Children's Hospital Los Angeles, which means that I uh support our nursing um education and simulation um and some research efforts here at CHLA.

SPEAKER_02 16:03

I feel like we've got uh so many pressures on nurses as they come out of school and as they as they enter the workforce. Tell me what you're seeing and some of the things that you know we're doing as we think about pathways for nurses.

SPEAKER_00 16:18

Yeah. I think that the healthcare environment is so complex. And the nursing education programs or health education programs really are, you know, relatively short in length, especially in nursing, and don't often give a lot of rich clinical time to get that experience to be working in such complex environments. And so one of the biggest challenges we see is that we have newly graduated nurses who are so eager to start their career, but they really lack a lot of clinical experience. And so it's a huge leap for them to jump into the clinical space and be ready to take care of the complex patients and families that we serve. And so I think we've had to do a lot of thinking about how we better prepare nursing students to uh to make that leap and to really join in and um be really contributing members of our workforce. And it's uh continues to be a really big challenge as things become even more complex and you know, the the environment is changing so quickly.

SPEAKER_02 17:22

So today, a nurse on average enters the workforce. Is it typically a few years after their undergraduate studies?

SPEAKER_00 17:30

Yeah, it really can vary because we have um such a variety of programs in nursing. Most typically, though, our new graduate nurses are coming right out of their four years of their bachelor program or perhaps even two years of an associate degree program. We do have a subset of graduates who have had some sort of professional career and then make a switch to nursing, but the largest proportion of our workforce are fairly young, coming right out of their academic programs. And so they also don't have um necessarily a ton of life experience to reflect back on and to use to inform their practice.

SPEAKER_02 18:02

Yeah, that's what I was kind of getting at. So whether it's the life experience or even just professional experience, what are some of the challenges that they would face in a complex pediatric environment like ours that could make it challenging for somebody who is kind of new into the workforce?

SPEAKER_00 18:19

Yeah, absolutely. I think there's um both the mastery of the um the actual tasks of um delivering nursing care, but then just as much so and many days more so, the complexity comes from working with, in the case of pediatrics, both children and their families who are experiencing a health crisis or who have perhaps long-standing and complex illnesses, and all of the social factors that kind of play into that and be can be contributing to their illness or make it difficult for them to access care. And certainly in our kind of post-pandemic world, I've seen a big increase in the in the social complexity of some of the families that we care for and the challenges they're facing. And so this, you know, relatively novice nurse who's coming into the workforce, needing to deliver all of the nursing care that they've been asked to deliver while also interacting, connecting with patients and families, that's really a tall order and a big task for someone to be able to do.

SPEAKER_02 19:20

So, what are some of the exciting innovative things that we're doing at Children's Hospital Los Angeles to help with this?

SPEAKER_00 19:26

We're actually really excited about a relatively new program that we've started where in year three of what we call the Pediatric Pathway Program, we're partnering very closely with, at this point, three different schools of nursing, each of whom have committed to allowing us to experiment a little bit, to stretch their curriculum so that we can have dedicated time with their students in a much more comprehensive way than they had traditionally done. So typically, a nursing student has a very limited amount of their clinical hours done in pediatrics, and they might only get a handful of shifts in the hospital, and so very limited exposure to the world of pediatrics. With these pediatric pathway program schools that we're partnering with, we've tripled and quadrupled the number of hours that the students are spending with us. And so that allows us to make sure that they have exposure to a wide variety of settings that nurses practice pediatrics in and just have more time in each of those settings so that they can really see the different types of patients that we care for. They can have more time to practice skills that they need to master in order to deliver safe and high-quality care. And they really get a sense, a much better sense of sort of the culture of CHLA, how we deliver pediatric care, how we interact with families and each other. And so it sets up that sort of sense of enculturation of is this an organization that they might want to consider working at and what would it really feel like to be a pediatric nurse? So it's been a really exciting journey, and we've been really creative about thinking about all the different exposure opportunities that they have and all the different settings. Typically, nursing students are spending most of their time in inpatient units, and we've had an opportunity here to expose them to ambulatory spaces and some community health work, all of it focused around pediatrics, so that they walk out of the program knowing either positively or negatively what it's like to be a pediatric nurse and whether that's right for them.

SPEAKER_02 21:31

I'm both amazed by what you're doing and at the same time surprised that this isn't the norm. This feels like something that if you're entering a practice and you're going through school, you want to be able to experience what it looks like more than just a few times. Like it feels like immersion is is key, especially in a field that's so complex, like nursing and pediatric nursing on top of that.

SPEAKER_00 21:54

Yeah. In nursing, we've had this paradigm around creating generalist. Nurses. And so that means we're trying to get make sure that every nursing student has a little bit of exposure to all the different types of nursing. And while there's certainly some value in that in terms of helping people understand the different ways that nursing's practice, I think the downstream and downside impact to that is that we don't then allow students an opportunity to really experience what it's like in particular settings, especially in specialty settings like pediatrics or OB or psychiatric care. And so we're really trying to shift the paradigm a little bit and say, you know what, there is a group of students who have some sense that they really want to work in pediatrics or maybe they really want to work in psychiatric care. And how do we develop programs that support that while also maintaining the exposure to the other areas that they need in order to be successful in their licensure examination and to have that generalist lens, but also it's sort of generalist with specialist and giving them that extra time and immersion, as you said.

SPEAKER_02 23:01

Are you starting to see results? I mean, you said we're three years into the program. What how is it going so far?

SPEAKER_00 23:06

Yeah, so we're entering our third year. We've just graduated because it's a two-year program, and I think that really speaks to the length and the duration and the intensity of the immersion. We've just graduated our first cohort, and many of them are applying to enter our RN residency program. So their first job out of school. And so we've been able to hire just about half of those students who applied, and we'll be tracking to see, we expect to see both stronger for retention rates of those students because they really do have a really good sense of what they're jumping into, as well as we anticipate some shortening of the length of time that it takes to train them until they can be practicing independently. And that, of course, then gets them to independent practice more quickly and feeling sort of accomplished in being able to do that, but also has some financial implications for the organization because the amount of time that they're in training is quite costly for the organization. So we hope there's a financial impact as well.

SPEAKER_02 24:09

You said you also oversee simulation, right? So is there a role for simulation labs to help these new nurses or even nurses in training get better prepared for the realities of a job in nursing and pediatrics?

SPEAKER_00 24:24

Yeah, absolutely. I think most schools of nursing at this point use simulation, but what the gap continues to be as it relates to these specialty areas like pediatrics is that they may not have faculty who have expertise in the area. And so one of the components of the Pathway program is that we do have the students rotate through the simulation center and have really strong, well-developed simulations that are reflective of practice at CHLA. And so they get that chance to experience what it would really be like. And this the simulations are developed by pediatric nurses with expertise in simulation. So that's another enhancement. We'd like to do some more work in the future with supporting uh other schools of nursing to have that pediatric expertise in supporting their development of their simulations so that uh the SIMs are even more realistic and more reflective of actual pediatric nursing care.

SPEAKER_02 25:23

That's great. If there was somebody in high school today listening or, you know, a parent of a child who's in high school, why should they go into pediatric nursing?

SPEAKER_00 25:32

Pediatric nursing is the best. I think the opportunity to care for patients from infants all the way up to adolescents and young adults, and to care for their families. As much as that can sometimes be challenging, it's also the like most enriching part of being a pediatric nurse is really that holistic family approach to care. I think that there's a lot of just innovation that happens in the pediatric space, new ways of caring and and delivering therapeutics that are really pushing the envelope. There's always something new happening. There's always a new kind of patient that uh has uh, you know, a rare disease that you've never encountered before in your career. So it keeps you thinking and learning. And the type of people who tend to end up in pediatrics just are really fun and passionate about the work that they do. And so it's been just the um best choice that I certainly ever made um in my career to work in pediatrics and I think a really um energizing and uplifting opportunity for nursing students coming out of into practice.

SPEAKER_02 26:39

Very well said. And if you happen to go into nursing, you've got this great program here that I still can't believe it's it's interesting to me that this is novel. Because if you think about med school, yep. In med school, they've got rotations where they dive deep before they choose their residency. And I feel like there's some parallels to that in what you're describing here. Yeah, it seems like it's a deeper rotation, you know.

SPEAKER_00 27:04

Yeah, I think so. I think in med school it does, and and they have longer um amount of time to do the training. I think we have capacity issues kind of across the state. And so the the board of nursing has said for most specialties, there's only a 30-hour um minimum requirement. And so 30 hours is at best three shifts in the hospital, and that becomes observational at a certain point and not experiential.

SPEAKER_02 27:30

Yeah, super cool. Dr. Jenny Baird, thank you for joining us. Appreciate it.

SPEAKER_00 27:34

Thank you. Glad to be here.

SPEAKER_02 27:37

All right, thank you for joining us for your dose of optimism. Make sure to check out our show notes to get more information about our guests and the work they're doing. Visit our podcast page on the Kids X website to join our podcast community and to learn more about pediatric innovation. Thank you to our sponsors and to our presenting partner, Kids X. Please subscribe wherever you get your podcasts. And remember, it takes a village to make sure our kids grow into healthy adults. So volunteer at your local library, help out at the community center, and if you're so inspired, donate to your local children's hospital. Alright, see you next time. The content, views, opinions, and information presented on this podcast do not reflect the views at Children's Hospital Los Angeles or of the sponsors of the podcast.