- Children and families require a child health care system that serves their unique needs and supports opportunities for life-long health and well-being.1 The current system, however, fails too many children, especially Black, Indigenous, Latino, and other children of color.2
- Expanding the focus of pediatric care beyond medical care — to encompass connections between children, families, communities, and the systems they interact with regularly — promises significant benefits for child health and well-being, particularly for children of color.
- Through insights from health care leaders across the nation, the Center for Health Care Strategies (CHCS) identified three key strategies that are integral to child health care transformation: (1) adopt anti-racist practices and policies to advance health equity; (2) co-create equitable partnerships between families and providers; and (3) identify family strengths and health-related social needs to promote resilience.
- The report provides practical recommendations for providers, payers, and policymakers to consider adopting approaches to transform child health care delivery. It also explores barriers to widespread implementation and identifies critical accountability and financing levers to support and sustain improvements in pediatric care.
Pediatric health care providers and their multidisciplinary care teams are uniquely poised to affect life-long health and well-being by supporting opportunities to prevent development delays, address health-related social needs, and reduce the risk of chronic disease, trauma, and mental health difficulties. If pediatric health care were consistently anti-racist, strengths-based, and delivered in partnership with families and communities, more children would have access to the relationships, resources, and care they need to thrive.
Drawing from conversations with child health care leaders nationally and a literature review, CHCS, with support from the Robert Wood Johnson Foundation, identified three key strategies that are integral to support a more upstream, preventive, holistic pediatric delivery system model that treats all patients with dignity and respect. These strategies create the underpinnings for improving children’s health care beyond medical care, centering child and family well-being, and incorporating an upstream approach to prevention.
Following is a summary of key strategies for improving child health care and a small subset of practical recommendations for providers, payers, and policymakers to consider adopting.
Racism, a driver of health inequities, is experienced in the health care system by patients, caregivers, and providers alike and is reinforced by policies, practices, and interpersonal relationships.3 Health care providers and institutions, including pediatric practices, have an opportunity to not only acknowledge historical and current racism in medicine but to dismantle racism in health care through explicit efforts, such as establishing anti-racist policies and practices that can disrupt systemic racism and promote equity among all groups.4,5 Child health care providers can hold their organization and staff accountable to anti-racist practices and play an important role in combatting racism within their own communities.6,7
Examples of provider-based anti-racist practices to promote health equity include:
- Promote an environment of mutual trust and respect, rooted in dignity, to validate feelings that families of color express about their health care treatment, ensure that interventions are responsive to families’ unique needs, and consider beliefs and cultural backgrounds in planning and delivery of care.8
- Provide cultural humility, implicit bias, and race equity trainings for staff, encouraging trainers with lived experience of racism to share their storieswith practice employees, and urging all participants to deepen their understanding of how current systems and organizational practices may contribute to discrimination against marginalized populations in the medical setting. Following formal trainings, encourage regular group reflection across the organization.
- Develop recruiting strategies to more closely align the racial and ethnic makeup of providers and organizational leadership with that of the patient population.
Families are a powerful force for sustaining child health and life-long well-being. The medical team should recognize family members as experts on their family and invite them to serve as equal partners. Valuing a family’s autonomy, expertise about their child, and perspectives creates an opportunity to gain their confidence and establish a trusted partnership. Children have a better chance of receiving care they need when their caregivers are confident that they are being heard and feel comfortable asking questions of their child’s health care providers, providing context to inform the care plan, and openly sharing areas of struggle or need. By engaging family members as equal members of the care team, health care practitioners can build on a family’s strengths and co-create care plans that are more likely to achieve better outcomes.
Examples of ways to create equitable partnerships between families and providers include:
- Incorporate screening practices for the whole family as appropriate during pediatric visits, for example, the Bright Futures Pediatric Intake Form and the Resilience Questionnaire — which seek to identify family strengths in addition to Bright Futures.9
- Connect families to community supports, such as play groups, library time, fatherhood initiatives, and peer-to-peer programs, like Parent to Parent10 for families with children with special health care needs, to foster much-needed support systems. Providers can also connect families to home visiting models most appropriate for them.11
- Design family engagement practices alongside family representatives, for example, through family advisory councils to encourage integration of family voices into the clinic setting and solicit family feedback regarding practice culture changes, how patients and families are treated, and their connections to community-based resources.12
Many public health experts suggest that medical professionals and their teams should incorporate addressing health-related social needs as part of their routine visits, in addition to screening for social, economic, and environmental drivers of health.13,14Encouraging a patient or their family to define their own needs alongside the clinical expertise of the pediatric medical team allows a family to inform their care in ways that are equitable and promote resilience. When families are empowered to define their own priorities, addressing health-related social needs in partnership with the provider can help close gaps in critical unmet needs and improve the quality of care for children and their families. Fulfilling social needs for children, particularly those living below the poverty line, encourages positive health, developmental, and educational outcomes.15
Examples of ways for practices to identify family strengths and health-related social needs include:
- Co-create an eco-map,a diagram that depicts a family’s most important personal and community relationships, to better understand a family’s strengths and help families identify challenges or resource gaps to prioritize.16
- Provide education and guidance for all medical care team members on the importance of screening with dignity, respecting a family’s decision to refuse screening, and understanding the risks associated with screening, particularly for families of color.17
- Develop partnerships with managed care organizations to support resources and referral pathways for children and families.
Widespread adoption of the above key strategies within the pediatric practice setting requires new accountability and financing structures to support enhanced approaches to care. Despite a growing desire to transform child health care, many practices struggle to implement improvements in care due to restrictions in time, funding, and capacity, as well as barriers within health systems that inadvertently prevent the scale and spread of these efforts. Following are primary levers to support, scale, accelerate, and sustain child health care transformation efforts.18
- Accountability measures that are patient-centered, focus on the specific developmental needs of children, and gauge progress in addressing racial and ethnic health disparities can better support child and family well-being. New metrics that reflect the multidimensional nature of health are needed at the practitioner, community, and policy levels to assess child and family well-being, track performance, incentivize practice change, and increase accountability in pediatric settings.
- Financing structures that encourage investment in healthy child development and upstream prevention while providing flexibility for providers can support these goals.A shift toward financing models reflecting value and quality of care will support efforts on the clinical, community, and policy levels to advance anti-racist practices, co-create meaningful strengths-based partnerships with patients and families, and address health-related social needs.
In taking steps to transform how care is delivered at the practice level, providers, health system leaders, payers, and policymakers can collaborate to accelerate the pace of child health care transformation in the U.S. These collective efforts provide opportunities to drive the health care system to support a healthier trajectory over the life course for millions of children across the nation.
- G. Flores, and The Committee on Pediatric Research. “Technical Report- Racial and Ethnic Disparities in the Health and Health Care of Children.” Pediatrics, 125 no. 4 (2010). Available at: https://pediatrics.aappublications.org/content/pediatrics/125/4/e979.full.pdf
- Y. Negussie, A. Geller, J.E. DeVoe (Eds.). Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington (DC): National Academies Press, 2019, Available from: https://www.ncbi.nlm.nih.gov/books/NBK551489/
- M. Jenco. “‵Dismantle Racism at Every Level’: AAP President.” AAP News, June 1, 2020. Available at: https://www.aappublications.org/news/2020/06/01/racism060120
- Penguin Random House. “Extracts: Ibram X Kendi defines what it means to be an antiracist.” Available at: https://www.penguin.co.uk/articles/2020/june/ibram-x-kendi-definition-of-antiracist.html
- American Medical Association. “Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.” Available at: https://www.ama-assn.org/system/files/2021-05/ama-equity-strategic-plan.pdf
- R.K. Legha, D.R. Williams, L. Snowden, J. Miranda. “Getting Our Knees Off Black People’s Necks: An Anti-Racist Approach to Medical Care.” Health Affairs, November 2020. Available at: https://www.healthaffairs.org/do/10.1377/hblog20201029.167296/full/
- J.N. Olayiwola, J.J. Joseph, A.R. Glover, H.L. Paz, D.M. Gray II. “Making Anti-Racism A Core Value in Academic Medicine.” Health Affairs, August 2020. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200820.931674/full/
- Institute for Patient- and Family- Centered Care. “Patient- and Family-Centered Care.” Available at: https://ipfcc.org/about/pfcc.html
- “Pediatric Intake Form.” Available at:https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdfInsert full endnote here.
- For more information on Parent to Parent, USA. see: Parent to Parent. Available at: https://www.p2pusa.org/
- National Home Visiting Resource Center. “Models.” Available at: https://nhvrc.org/about-home-visiting/models/
- S.B. Frampton, S. Guastello, L. Hoy, M. Naylor, S. Sheridan, M. Johnston-Fleece. “Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care.” NAM Perspectives, 2017. Available at: https://nam.edu/harnessing-evidence-and-experience-to-change-culture-a-guiding-framework-for-patient-and-family-engaged-care/
- 13S. Morton. “Managing Health-related Social Needs: The Prevention Imperative in an Accountable Health System.” John Snow, Inc. Available at: https://www.jsi.com/managing-health-related-social-needs-the-prevention-imperative-in-an-accountable-health-system/
- B.C. Castrucci and J. Auerbach. “Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health.” Health Affairs, January 2019. Available at: https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/
- K. Jenson and B.M. Cornelson. “Eco-Maps: A System Tool for Family Physicians.” Canadian Family Physician, 33 (1987): 172-177. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218299/
- D. Schleifer, A. Diep, K. Grisham. “It’s About Trust: Low-Income Parents’ Perspectives on How Pediatricians Can Screen for Social Determinants of Health.” United Hospital Fund, 2019. Available at: https://www.publicagenda.org/wp-content/ /2019/08/itsAboutTrust_UHF_Final.pdf
- InCK Marks resources related to child health care transformation. Available at: https://www.inckmarks.org