L.A. County Debates Role of Public Health Nurses in Child Protection

A June 30 report calling for the termination of Los Angeles County’s experimental public health nurse program has sparked a rich debate about the role of such nurses in child abuse investigations.

County leaders have questioned whether terminating the experiment – less than a year after it launched – would be premature. Meanwhile, a handful of department heads, public health professionals, social workers and private service providers would either happily see the program go or would work to see it improved.

The ranging viewpoints make for a portentous early test of another county experiment: the Office of Child Protection, which issued the now-debated report.

Both the public health nurse program and the Office of Child Protection were part of an exhaustive slate of recommendations made by the Blue Ribbon Commission on Child Protection in 2014.

That commission was created in response to a 2012 report and the brutal death of an 8-year-old boy, which both revealed serious problems in how the county responds to signs of abuse and keeps children safe.

Novel Approach  

The public health nurse program was created to ensure that all investigations of child abuse for children under the age of 2 are conducted in tandem by social workers and public health nurses. The idea was that a second pair of eyes would help better discern signs of maltreatment.

“The recommendation was based on a desire to strengthen prevention,” said Marilyn Flynn, one of the blue ribbon commissioners and the dean of the University of Southern California’s School of Social Work, in an email. “There is considerable evidence supporting home visits to promote better parenting of very young children, a group at highest risk of serious abuse.”

But when county officials searched across the country for programs that sent nurses out on every investigation of child maltreatment involving infants and toddlers, they found none.

Despite this, the Board of Supervisors unanimously approved a plan in January 2015 to test the experimental program. It would be rolled out at three sites known to have heightened rates of suspected and confirmed child abuse.

The program’s designers selected the Department of Children and Family Service’s (DCFS) Compton and Vermont Corridor offices. An additional public health nurse and supervisor were placed at the department’s Emergency Response Command Post to respond to after-hour calls that warranted an investigation. Taking the program countywide would cost between $19.6 and $25 million, according to the June report.

From the outset, the goals of the program were, if not conflicting, incongruent.

An implementation plan drawn up by the county’s Chief Executive Office said that having nurses present would help catch signs of dangerous abuse, which could ratchet up the likelihood that children would be removed from their homes. The plan also contended that the program could be helpful in increasing the number of “children who can remain safely at their homes.”

In an interview, DCFS Director Philip Browning pointed to this uncertainty.

The expectation was, “there would be more kids detained and taken out of the home,” Browning said. But he also said that he and others hoped that the nurses would be able to keep social workers from making a “snap judgment” about something like a common bruise, and deeming it cause for removal.

Jeanne Smart, who directs perinatal home-visiting programs within the Department of Public Health (DPH), said in an email that the program “was never fully planned out with concrete strategies, measurable objective outcomes or adequate training for the nurses.”

Smart said that public health nurses could be “extremely valuable” in serving pregnant and parenting teens and medically fragile newborns. “Unfortunately, county PH [public health] nursing is slow in meeting the evidence-based standards that are now the hallmark in program evaluation.”

By the time the pilot was launched in August 2015, Browning said that “a lot of changes had been made in how the program was going to operate.”

Less than two months ago, a social worker at DCFS’ Command Post went to a home to conduct a child abuse investigation.

The worker, who asked to remain anonymous, had five days to close the case.

Because one of the six children in the home was under the age of 2, the social worker needed to schedule with the public health nurse so that she could join him on the initial investigation. But she was on vacation, so he conducted the visit alone.

When he got there, he checked all the children for bruises, asked about any medical conditions and found out who the children’s primary doctors were.

“I do the entire job of a PHN [public health nurse] when I go out,” he said, clearly frustrated.

Because the public health nurse was unavailable during the first five days of the investigation, the social worker was required, under the experimental program, to go back out again with her as soon as her schedule permitted it. Because one of the six children was not there when they later went out to the home together, they had to conduct yet another visit, which pushed the case past the 30-day deadline to finalize a child abuse investigation.

“All I am doing is just standing there like a bodyguard, which is a waste of time and my schedule, because I have other referrals that I have to close out in 30 days,” the social worker said.

Experimental Office

While DCFS worked to implement the program, the Board of Supervisors created the new Office of Child Protection and spent months seeking a leader to run it.

The office was established to orient all the public agencies that serve children toward improving prevention and the detection of child abuse while also coordinating faster, more effective responses when maltreatment does occur.

In November 2015, four of the five members of the Board of Supervisors voted to appoint Michael Nash as the office’s director. Nash, who had previously served as the presiding judge of the county’s juvenile courts, came into the job with a reputation as a straight talker unafraid to question the status quo in the name of children’s rights.

In earlier versions of what would become the final recommendations of the blue ribbon commission, the leader of the Office of Child Protection would have been granted power over budgets and personnel. By the time the final recommendations were issued in April 2014, those powers had been stripped away. Instead, the Board of Supervisors has the final say on any recommendation Nash makes.

“We want him to be about child protection,” said Supervisor Sheila Kuehl. “But the buck stops with us.”

Given this dynamic, Nash’s first report to the board and its recommendations provides a window into how effective he and his office can be.

Healthy Debate

Beyond calling for terminating the public health nurse program, the June 30 report recommends consolidating the 103 public health nurses who work for DCFS under the Department of Public Health.

The report, which covers the first seven months of the public health nurse program’s implementation, found that a staff of 17 public health nurses and three supervisors spread across the three DCFS offices conducted a total of 1,307 visits alongside social workers. The report did not include any data on whether or not children involved were more likely than peers who did not receive joint visits to become suspected or confirmed victims of child abuse.

While devoid of clear safety metrics, the report did find that public health nurses identified unmet medical needs for 40 percent of the children they saw, and generated 1,178 referrals for medical services.

To augment the lapses in data, Nash spoke to public health nurses, social workers and other staff in the departments involved to better understand whether the program was increasing child safety.

“Since implementation of the program demonstrated more of an impact on early intervention instead of safety, a decision needs to be made whether this is a sufficient basis to continue this program,” Nash wrote in his June 30 letter to the board that accompanied the report.

He determined that the program should be terminated. In its place, he called for enhanced training for social workers on identifying medical needs and “further discussions on how PHNs [public health nurses] can be more efficiently utilized within existing resources.”

Two Los Angeles County supervisors – and the assistant chief of staff to another – questioned whether the program should be ended so soon.

Supervisor Mark Ridley-Thomas, one of the lead proponents of the Office of Child Protection, said of Nash’s recommendation: “It may be a little early to draw that conclusion.”

Supervisor Kuehl welcomed Nash’s recommendations but needed more information before accepting them on their face.

“Judge Nash was the head of the juvenile court and is used to being decisive and often says what he thinks, and we [the board] were very excited about that,” Kuehl said. “I am not criticizing him about that.”

But, she added, “We need to be a little more evaluative.”

Nick Ippolito, assistant chief of staff to Supervisor Don Knabe, who voted against hiring Nash, said that his office was “not willing to say this program is a failure, and that we are willing to tank it.”

In addition, Ippolito said that Nash’s recommendation to train social workers on medical needs was “preposterous.”

And former Blue Ribbon Commissioner Flynn said that she thought it was “extremely premature to claim to measure effectiveness,” as Nash’s report did.

Mitchell Katz, the head of the county’s Department of Health Services, which oversees the Department of Public Health, said that while Nash’s recommendation “was not artful,” it was an important step towards better integrating public health nurses in child protection.

“In the pilot, the people on the ground felt that having the public health nurses automatically go out on all of the visits wasn’t producing a great amount of benefit,” Katz said. “I have no reason to disbelieve them. But that doesn’t mean the program should be stopped. It is a moment to ask what is the best use of the public health nurses.”

Others in the child protection community think that Nash’s recommendation was dead on.

“I agree with Mike [Nash] wholeheartedly,” said Kathy Icenhower, the CEO of SHIELDS for Families, a child welfare and mental services provider, in an email. “Money could be better spent elsewhere.”

DCFS’ Browning also agreed with Nash’s recommendation, saying that the cost of the program would be better spent towards hiring 1,000 new social workers.

And the Command Post social worker said he “totally agreed with Judge Nash.”

Beyond the debate around terminating the public health nurse program, Nash’s recommendation to consolidate all the DCFS public health nurses under the Department of Public Health was well received.

“I do believe that all the public health nurses should report out of the Department of Public Health, because I think they would be stronger under a nurse-led supervision,” Katz said. “That is something we can make happen in the next few months.”

Anna Long, the director of children’s medical services for DPH, concurred.

“Public health nurses belong in public health,” she said.

DCFS Director Browning agreed.

When asked whether the reaction to his first report to the board was an important yardstick of how effective the Office of Child Protection would be, Nash grew thoughtful.

“I think it is a good learning experience for me in understanding how the board works and evaluates reports and recommendations,” he said.

“They brought me in to give certain things: a look and recommendations,” Nash added.

“I was not brought in as a yes man, and so I am going to do my work as best as I can, and each time I do something, I will learn how to do the next piece of work even better.”

However “artful,” Nash’s first report as the director of the nascent Office of Child Protection has people up and down the county considering the hard question of how to integrate public health into child protection.

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