PolicyLab

The reorganization of health care systems to provide more accountable care to the populations they serve has been a hallmark of health reform. In pediatrics, the move toward accountable care organizations – which the Affordable Care Act highlighted but left undefined – provides an opportunity for an emphasis on, and innovation in, family-centered care.  A core value of the Affordable Care Act is patient-centered care with a triple aim of quality, value, and patient experience. For children, this must translate into family-centered care.

Family-centered care means an inclusive relationship between the clinician and all members of the family, emphasizing shared decision-making on behalf of a child. In recent years, the true innovation in family-centered care is the increasing recognition that a parent’s own health outcomes are critical for achieving improved health outcomes in children. In other words, best practice in family-centered care for a child means providing intergenerational family services.

The importance of intergenerational family services

The integration of services for parents and caregivers is needed in pediatric health systems, whether through direct care (e.g., screening and treatment for maternal depression in pediatric practices), or through community-based partnerships between pediatric health systems and local non-profits (e.g., home visiting services connected to pediatric practices in high-risk settings). In the United States, one in five children live in households with parents experiencing symptoms of depression, and for children in low-income and single-parent households, the proportion with depressed caregivers is even higher. Parental depression is associated with high levels of stress and decreased competence in important parenting skills. It has been linked to adverse child development outcomes, including difficulty regulating emotions and decreased cognitive performance. An accumulating evidence base is demonstrating that child outcomes are boosted when a parent receives needed mental health services, or when a parent is included in a treatment model. For example, behavioral outcomes for troubled children become muted in real-world practice, unless the services they receive also coincide with the delivery of needed mental health services to a parent.

Even beyond mental health, we are beginning to see the true value of intergenerational approaches to health care as a strategy to improve the health and well-being of children.  At PolicyLab, our investigators are exploring intergenerational family approaches for a variety of pediatric services, demonstrating time and again that achieving outcomes in children requires an approach that includes parents and their needs. From vaccine delivery to parental reproductive health to obesity prevention to the provision of effective parenting and infant home visitation models, the message is the same: children do better when their parents do better. Visit our intergenerational family services webpage, and you will see a sampling of project profiles in which pediatric care is changing to incorporate intergenerational family services.

Advancing novel policy solutions

There is no doubt that we will continue to see strong growth in intergenerational family approaches as we continue to move toward accountable care. Less certain is whether the market will be ready to embrace these challenges. The bureaucratic, fragmented world of health care coverage is likely to impede the type of integration that will be necessary to sustain this innovation in practice. On the health care coverage front, we are now seeing families increasingly split health coverage across employer-sponsored plans, the individual exchange and public insurance markets. Such splitting – which may be pragmatic as the cost of health insurance rises – can nevertheless act against the growth of intergenerational approaches at the point of care.

Given this, it will be critical to advance novel policy solutions that can create a more permissive environment for intergenerational models in pediatrics. The degree that Medicaid expansion in many states is offering needed coverage to previously uninsured parents is a great first step. However, Medicaid expansion alone is unlikely to push pediatric health systems toward targeted services for parents. States will also need to consider how to reduce the administrative burden for those systems, perhaps by reducing regulatory/credentialing requirements for pediatric systems that deliver care to parents. States expanding Medicaid might also consider presumptive Medicaid eligibility for certain adult services to be delivered in non-routine settings like pediatrics. For example, New York’s presumptive eligibility for reproductive health services for women provides a terrific opportunity to link reproductive health services to adolescents and young adult parents in and around pediatric settings.

But let’s not stop there. Let’s think about ways that the Centers for Medicare & Medicaid Services can support states that want to create Medicaid “family accounts”, which are billable for both children and parents and only have a single credentialing requirement. Very few would argue that treatment for maternal mental health issues is not in the best interest of the child. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit was created on the basis of insuring a core set of essential health care and developmental services to maximize the health and well-being of U.S. children. Linking certain services for parents to EPSDT could reduce stress and harm to their children.

The policy options to address the provision of intergenerational family services are many and include short-term, low hanging fruit (mental health screening and referral) and long-term solutions (payment reform). For sure, this is an area in which the evidence related to the benefit of an intergenerational approach is out way ahead of policy. Aligning state and federal policy to create incentives for true family-centered care is critical to delivering on pediatric accountable care.