Supercharging change
With a big boost from a new grant, UT Health San Antonio is creating a medical home for families receiving foster care services, working to end a cycle of inconsistent care to a population in great need
By Karla Hignite
Brenda Hernandez thinks foster care kids are superheroes.
“It’s not easy to be ripped from the family you know — even if from an unsafe setting — and to spend the next however many years moving from place to place, not knowing what happens next,” said Hernandez, a School of Nursing Doctor of Nursing practice program student.
“I was in the same foster home twice, the same foster facility twice and went to the same emergency shelter four times.”
Hernandez was emancipated from Texas’ foster care protective services program 32 years ago when she turned 18, but she still has vivid memories of the three or four black trash bags containing her life’s possessions that she toted with her each move.
“Then when you leave the system, one of hardest things is figuring out where to go,” said Hernandez. “It’s like, ‘now what?’”
Her next step was to apply to San Antonio’s Our Lady of the Lake University for reasons both personal — the high expectations she set for herself — and practical: The college had dorms, and she needed a place to live.
Bachelor of Science in Nursing student Mari Segna also grew up within the foster care system, first in Texas and then in New Mexico after she was adopted at age 12. She remained in New Mexico until 2009. It was during the economic slowdown of the Great Recession when she was working three jobs that Segna wound up homeless for a time.
The day she planned to move back to San Antonio to live with her older sister, she discovered her car had two flat tires. So, she withdrew the final $125 she had in her bank account, packed a box of clothes and took a bus instead.
Through different journeys, both Hernandez and Segna are using the State College Tuition Waiver to attend UT Health San Antonio. The program exempts or waives payment of tuition and fees at state-supported colleges or universities for those currently or formerly in the conservatorship of the Texas Department of Family and Protective Services (DFPS), so long as they have enrolled in a state-supported college or university before their 25th birthday.
And, both Hernandez and Segna represent the kind of positive story that Debbie Jennings wants to amplify and multiply.
“Our primary mandate is to ensure these children and youth who are receiving foster care services get the sustained, comprehensive care they need.”
— Karen Schwab, PhD, APRN, CPNPPC, PMHS
Advocate for the unprepared
Jennings, DNP, MSN, RN, CENP, a clinical assistant professor at UT Health San Antonio, is particularly drawn to “the big kids” — those who will soon be thrust into adulthood — many of whom are unprepared for what that means or requires, said Jennings.
“Many haven’t had a consistent example or advocate, someone to help them navigate the basics of how to set up a bank account, pay bills, establish a household or make a medical appointment,” she said.
To that final point, Jennings feels a sense of urgency to counsel youth receiving foster care services to stay within the system until they reach their legal age of emancipation. Doing so ensures eligibility for health insurance coverage until age 26 and dental care until age 21.
“Otherwise, you are pretty much on your own,” said Jennings. She is often asked if she grew up within the foster care system. “I didn’t. It’s a population I’ve just been drawn to and has been on my heart for some time.”
As part of her doctoral work, Jennings began hosting health care workshops targeted to foster alumni who have transitioned out of the system. It was in this capacity that Jennings met Karen Walker Schwab and learned of the UT Health San Antonio School of Nursing’s Wellness 360 program and its designation as a Foster Care Center of Excellence.
Schwab, PhD, APRN, CPNPPC, PMHS, directs pediatric care at Wellness 360, providing pediatric primary care to the general public and, as a Foster Care Center of Excellence, specializing in the specific health care needs of children receiving foster care services.
Schwab is also the principal investigator of a four-year, $4 million grant from the Health Resources and Services Administration to expand foster care health services across the state’s Public Health Region 8, comprised of 28 counties in Central Texas and the Hill Country that extend from Del Rio to Victoria.
Filling the care gap
“Our primary mandate is to ensure these children and youth who are receiving foster care services get the sustained, comprehensive care they need,” said Schwab. Providing consistent care to this population poses an additional challenge because they are often moving from place to place.
“Because their medical records may not follow them through multiple placements, there is often a lack of history of past treatments,” explained Schwab. As a result, many of these children are in danger of developing a significant medical condition.
“As many as two-thirds of the children and youth we see may also have a chronic condition like diabetes or asthma that has simply gone untreated and even undiagnosed due to an inconsistent care regimen,” said Schwab.
Beyond often being delinquent on childhood vaccines, the No. 1 issue for many of the children is untreated mental health concerns, Schwab said. Children and youth in the foster care system often have some level of trauma, neglect or abuse, she added.
“Our goal is to create a medical home for children and youth receiving foster care services — to become a one stop shop offering consistency of treatment across the full spectrum of care they need,” Schwab said.
Care to the community
Under the state’s new community-based care model for foster care, the grant will help the School of Nursing establish health care hubs that bring community partners together to coordinate care.
“This isn’t new infrastructure. We’re not building anything,” said Schwab. “Rather, we’re working with community partners and identifying established community center locations where we can coordinate care.”
For the near term, plans are underway to establish four hubs through the School of Nursing’s Wellness 360. According to Schwab, the school is currently in final stages of executing the memorandum of understanding with locations in New Braunfels — the first to open — and Crystal City.
“Providing community-based care through these hubs will help ensure that these children and youth don’t miss appointments, and we can better track their health history to ensure we also aren’t duplicating services,” said Schwab.
To assist in that effort, the School of Nursing’s mobile health unit will bring health care expertise into rural communities so that registered nurses, community health workers, nurse practitioners and other providers and experts can offer a central location for medical services not only for children and youth receiving foster care services and for their family members, but also for the community at large.
The hubs will also bring advanced telehealth equipment to these areas to further expand access to medical appointments and services.
“Many haven’t had a consistent example or advocate, someone to help them navigate the basics of how to set up a bank account, pay bills, establish a household or make a medical appointment.”
— Debbie Jennings, DNP, MSN, RN, CENP
Training a rural care workforce
While the hubs address the practice portion of the grant, other grant priorities focus on educational components, said Schwab.
“We were already including students in our clinics and mobile unit events. Now we can incorporate a more formal curriculum, providing immersion experiences for students in rural and mobile health unit settings, with the ultimate goal of having students spend 80 clinical hours in a rural setting using mobile health or telehealth,” said Schwab.
In addition to training students on using the telehealth equipment to advance their health assessment skills, the curriculum will cover community outreach, health literacy and social determinants of health to familiarize nursing students with providing care to this vulnerable population. A virtual service-learning center will allow students and faculty to complete modules on specific practices, such as how to safely administer vaccines.
The grant will also support testing, recruitment and retention of a rural nursing workforce by providing rural health care providers with essential resources through a website that will debut later this year.
Building basic health literacy
With the push to ensure consistent, comprehensive care to children and youth receiving foster care services while in the system, what happens to those preparing to transition out of protective services?
“When youth are getting ready to age out of the system, they do have classes to help prepare them, but it can be overwhelming, with so much information competing for their attention,” said Jennings.
She spends about 40% of her time teaching in the School of Nursing and 60% connecting with foster alumni throughout the region to help them increase their health care literacy so they can better navigate the health care system.
“When I first started hosting workshops for this population, I realized very quickly that most youth receiving foster care services don’t know the basics. So, my workshops start with what an insurance card looks like, what health insurance does and doesn’t cover and how to choose a provider and make an appointment,” said Jennings.
“We do a lot of role-playing about how to ask providers questions if they don’t understand something, like what their blood pressure reading means. Many times, these youth don’t realize that they have a voice because for so long the foster care system has told them what to do.”
In addition to her workshops and training sessions, Jennings launched a YouTube channel to provide educational videos on a range of health care topics to boost basic health literacy. Because of a general lack of advocacy for the health care needs of those receiving foster care services, Jennings also got certified to be a health care navigator so that she can sign up foster alumni for health insurance.
Generational change
With the complementary roles of Schwab and Jennings focused on infants to young adults, they’re setting their sights on a generational change — not only to improve the health and well-being of children and youth receiving foster care services, but also to eliminate the stigma surrounding that experience.
Through her work, Jennings is in touch with students on public college campuses including Alamo Colleges, The University of Texas at San Antonio and Texas A&M University-San Antonio. She’s also an active participant with the Bexar County Fostering Educational Success project, which aims to improve college graduation rates for foster alumni by bringing together current and former youth with a lived experience of foster care to explore what they want to study, where they want to go and what they need to get there.
“Too many still aren’t aware of the tuition waiver available to anyone who has been within the foster care system, so we’re starting to identify those in middle school to make them aware of this benefit,” Jennings said. “If you survey youth receiving foster care services, 80% say they want to go to college, but about 30% get in, and 3% graduate. And in our region, it’s even worse, with only about 1.5% who graduate.”
That’s why Jennings wants to amplify and multiply stories like those of Hernandez and Segna who are breaking the mold and breaking the cycle of a system that for too long has placed low expectations on the children and youth within its care.
“These youth are amazingly resilient, especially considering what most have been through,” said Jennings. “They want to become thriving adults. They crave the tools to learn. They just need someone to show them their next steps.”
The superpower of Brenda Hernandez: empathy
With an associate degree in social work and a bachelor’s degree in nursing, Brenda Hernandez has already spent 19 years in various health care settings and roles working with a range of populations, from pediatrics to geriatrics to emergency room care. One early experience in her career was working as a patient care assistant at a hospital that had a psychiatric wing.
“Many of the psyche nurses had the medical care mastered, but I felt like some lacked an understanding of what some of these patients actually needed,” said Hernandez. She knows that becoming a nurse was one of the best decisions she has made in life.
“Nurses are the eyes and ears of patients. They know what’s going on and can make the biggest difference in how a patient feels and in that patient’s outcomes.”
Hernandez is a firm believer that connections can be made with every patient.
“You can find out a lot about your patients in casual conversations. Even the angriest patients will open up if you spend the time to find out what they care about,” she said.
Growing up, she saw many of her foster care friends wrestle with the trauma of their experiences.
“I remember many of them taking medications and some really struggling with substance use,” said Hernandez.
She is thankful that was not part of her own experience, but she understands why it is for so many.
“The pain surrounding the issues that separated you from your biological parents doesn’t go away. The uncertainty of everything else that follows can linger so that you continue to experience the trauma each time you face a new challenge,” she said.
From what she has seen professionally and experienced personally, Hernandez knows there aren’t nearly enough practitioners to help those who have experienced significant depths of trauma.
Of her experience as a foster kid: “Growing up in the foster care program has shaped my capacity to show empathy for other people and for their situations,” said Hernandez. “Pain is not only what you can see sitting on the surface.”
The superpower of Mari Segna: perception
Years spent observing dog behavior has sharpened Mari Segna’s perception of what motivates people, too. Her adoptive family raised golden retrievers and ran a rescue shelter where Segna encountered breeds with distinctly different personalities — from the confidence and strength of huskies to the playfulness of labradors to the intelligence of German shepherds.
“Understanding what they need helps you take better care of them,” said Segna.
Two years ago, during the height of the pandemic, a friend suggested Segna join her in working for the pet-sitting business Rover.com. Segna thought, “Why not?” Demand exploded to the point that she worked all but 12 days during 2022.
Rover is also how Segna serendipitously met Debbie Jennings, DNP, MSN, RN, CENP, a clinical assistant professor at UT Health San Antonio, whose dog, Dublin, became a regular client of Segna’s for twicedaily walks. Segna had already been thinking about nursing as a profession well before she met Jennings, who encouraged Segna to apply to the school’s BSN program.
“My biological mom passed away in 2015 from Type 2 diabetes that eventually led to organ failure. I watched her struggle with her own health the final years she was alive, and it made me reflect on the fact that I could have a better life,” said Segna.
Although she didn’t complete high school, Segna eventually completed her GED and enrolled in a business degree program while living in New Mexico.
“It took a few years to realize that wasn’t what I wanted to do,” said Segna.
Despite the many twists in the road she has traveled, Segna doesn’t consider any of it wasted time. Her business background and work experiences in the restaurant industry and elsewhere have taught her not only about planning and organization, but also about building relationships and trust with clients — useful skills she can apply to the care of patients and to better understand their pain and motivations.
Of her experience as a foster kid: “None of this is something to wish on anyone,” said Segna. “But it has helped me be more open to understanding people and more accepting of where they are at any given moment instead of where they may want to be.”
