When Natalie Boyle was getting treatment for cancer, she was able to count on family who lived near her home in Dallas, Texas, and could afford a nanny to help care for her 18-month-old twin daughters.
But when a friend from her mom’s group, Annie, was diagnosed with colon cancer, she confided to Boyle that she couldn’t afford to pay for someone to care for her 2- and 4-year-old children. Her mom had been watching the kids, but didn’t live nearby and couldn’t stay any longer. Annie was hoping to ask a friend to care for her children on treatment days and to care for them herself the rest of the time, but Boyle wanted to make sure she had more consistent support.
Boyle rallied her social network and used online crowdfunding to raise money to pay for a nanny for Annie’s family. Over time, more and more people who had seen Boyle's crowdfunding efforts online reached out asking for childcare help for their friends and neighbors going through medical crises.
“I joke that I accidentally founded a nonprofit,” Boyle says.
As the organization grew, the overwhelming need for childcare for sick caregivers became even more apparent. While in-home nannies were helpful for many, it was hard to scale and didn’t meet the needs of many families, especially those living on lower incomes. Boyle wanted to provide an option that was accessible to anyone who needed childcare while seeking medical care.
So she connected with Kavita Bhavan, MD, MHS, chief innovation officer at Parkland Health in Dallas, Texas, whose job is to develop out-of-the-box solutions to health system challenges. Boyle's idea was to launch a no-cost, on-site childcare center at the hospital for patients.
“As soon as I met her, I thought, ‘This is absolutely innovative,'" Bhavan says. “It’s basically the Ronald McDonald house in reverse — a safe place for children to reside while a parent is getting cancer treatment, for example.”
In 2020, researchers at Parkland surveyed women patients of reproductive age and found that more than half reported foregoing health care for lack of childcare. It was the number one reason given for missing both routine appointments and visits to address a medical issue, followed by lack of transportation and insurance, the survey found.
A few months later, in November of 2020, Annie’s Place at Parkland opened, named in honor of Boyle’s friend, who had died of cancer as they were preparing to open the center. In the nearly four years since, Annie’s Place has cared for more than 2,000 kids at no cost to the families.
“It’s allowed parents to attend thousands of medical appointments,” Boyle says. “Anecdotally, we know this is saving lives.”
It’s an approach that few hospitals have taken, but one that Bhavan believes is on the cutting edge of a growing movement to address social determinants of health.
Though there have been many health system interventions aimed at other non-medical barriers to health, such as housing, nutrition, and transportation, the conversation around childcare has been slower to develop, Bhavan says.
More than a decade ago, the U.S. Department of Veterans Affairs (VA) launched a pilot program to provide free childcare at three VA medical centers across the country, citing a survey that found that a third of veterans were interested in childcare services and 10% had canceled or rescheduled VA medical appointments due to lack of childcare. Today, only one center continues to run that program, though the agency intends to expand the program to VA facilities nationwide, according to press secretary Terrance Hayes.
Additionally, the COVID-19 pandemic brought to light the negative impact that lack of reliable childcare for health care workers can have on a functioning health system. Some hospitals are recognizing it as a major reason for health care professional absenteeism or leaving the medical workforce altogether and are bolstering their childcare offerings to boost retention, according to a 2022 KFF Health News article.
“We’re just beginning to understand that [lack of childcare] is a much more universal problem,” Bhavan says.
Building the framework
While Bhavan and other leaders at Parkland were enthusiastic about the prospect of free, on-site childcare, they recognized that it would be logistically challenging to get such a program off the ground.
“It’s unusual for a health system — let alone a large academic teaching hospital” to have a program like this, Bhavan says. “It’s a huge undertaking to create a community-based partnership.”
But with buy-in from the health system administration, Boyle’s organization, and philanthropic support, the hospital identified a building on campus and renovated it into an inviting and stimulating environment for young children. Health system leaders collaborated with Boyle’s team to set up a licensed childcare center and hire qualified staff — including bilingual workers to serve the large Spanish-speaking population served by the hospital.
Bhavan and her team focused on ironing out the logistics on the health system side, including coordinating a shuttle from the childcare center to other parts of the campus, setting up a referral system for providers, ensuring all communications are compliant with medical privacy laws, and establishing metrics and a dashboard to monitor progress. Researchers at Parkland Health and the 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, Bhavan says.
So far, Bhavan is encouraged by the community response. She’s heard many stories of success: a mom who had premature twins being able to entrust one of her twins to Annie’s Place while she bonded with the other in the neonatal ICU; a mom who received prenatal care for the first time at seven months pregnant with a safe place for her other child to stay during her appointments; and another mom who was able to finally schedule surgery for a tumor removal.
It’s stories like these that demonstrate how addressing patients’ basic needs can be beneficial both for the patient and the health care institution, as it can save the health system money and potentially improve long-term health outcomes, Bhavan notes.
“Every time you cancel a surgery, it’s worse for your health and you’re canceling an [operating room], that costs a lot of money,” she says. “Addressing social determinants of health related to childcare helps improve process and quality of care.”
The VA also recognizes the potential value that free childcare for parents receiving medical care could have for the people it serves. An agency report released in 2015 looking into barriers to women veterans accessing VA health care identified lack of childcare as a major barrier; more than 60% of women surveyed said that on-site childcare would be helpful. Currently, the American Lake VA Medical Center in Tacoma, Washington, is the only location that offers the service, but officials say there are more to come.
“The VA is actively working to implement childcare assistance services for eligible veterans enrolled in VA Health Care and have a qualifying VA appointment,” Hayes said in a statement to AAMCNews. “The VA plans to expand these services to additional VA facilities nationwide and is developing a reimbursement system for drop-in childcare services provided in the community during a veteran’s eligible VA appointment.”
Since Annie’s Place launched, it has expanded its services to any parent who needs childcare to attend a preventive appointment, receive medical treatment, handle any medical emergency, or to be able to drop off their other children during a sibling’s medical appointment. It also offers backup weekend care for hospital employees.
Because Parkland serves a population that is largely uninsured with some living well below the poverty level, Bhavan hopes that the impact of more patients getting preventive care and consistent medical treatment for illness could move the needle on addressing inequities in health.
“We’re looking now at clinical health outcomes to assess the impact of Annie’s Place and addressing childcare needs for our population,” Bhavan says.
Supporting health care workers
While supporting patients so they can show up for their medical appointments is part of the equation, another part is ensuring the health care workers who make it possible to receive high-quality health care are also present.
An analysis published in Health Affairs found that 100,000 registered nurses left the nursing workforce in 2021, with a variety of factors including retirement, burnout, and lack of childcare contributing to the drop, according to the authors. In 2023, AAMCNews reported on how several teaching hospitals considered the nursing shortage exacerbated by the pandemic to now be at crisis level. And the American Association of Colleges of Nursing points to research that shows that fewer nurses working is associated with a number of poor patient outcomes, including higher readmission and infection rates, as well as higher patient mortality.
In August 2022, KFF Health News reported that some hospitals were offering childcare as a way to retain nurses and other hospital staff. Bright Horizons, a company that runs childcare centers across the country, has partnered with dozens of hospitals to provide on-site childcare for employees. According to a survey of nurses commissioned by Bright Horizons in 2017, 70% of respondents said they’d missed a shift in the last six months because a child was sick or they couldn’t find childcare.
According to a 2024 Nursing Solutions Inc. report, the national average turnover rate for hospitals is 20%, and turnover costs a hospital an average of $56,300 per bedside nurse, meaning the average hospital loses between $3.9 million and $5.8 million a year in nursing turnover costs. Even a 1% reduction in turnover can save a hospital $262,500 a year, the report states. One business analysis by the Boston Consulting Group found that companies across sectors offering childcare benefits can see up to a 425% return on investment.
One hospital that KFF Health News featured in the article reported that 91% of workers whose children attended the on-site daycare indicated in a survey that it was the main reason they remained in their jobs.
Changing the conversation
Boyle says that health system leaders across the country have reached out to her hoping to launch an Annie’s Place on their own campuses.
“We can’t run a thousand childcare centers, but we are trying to find ways to share knowledge of how to do this,” says Boyle. Annie’s Place is already expanding. The location at Parkland is under renovation to double its size to meet the growing demand for its services, though it has remained open during the renovations.
Bhavan encourages leaders at other academic health systems to engage with community organizations who have expertise in childcare to build partnerships that can blossom into mutually beneficial services.
“Our strength is health care, while community-based organizations [like Annie’s Place] specialize in childcare,” she says.
And as researchers at Parkland continue to gather data to measure the effect of the program, Bhavan and Boyle hope that their work will bring the importance of childcare in medical settings into the spotlight.
“When you talk about the social determinants of health, most charts do not list child or dependent care on there,” Boyle says. “We are advocating [for it to be included, because] this is just as much of a barrier as many other things people think of, like transportation and stable housing. Providing childcare can save lives.”
