PolicyLab

As my family and many others across the country begin another school year, I am reminded how we can each do our part to better prepare children for success—academically and beyond.  Outside the classroom, there are many systems within the community that help advance outcomes for children. Evidence-based home visiting, child care and primary care, to name just a few, can play a role in improving child health and well-being and preparing children for entering early learning environments and school. Specifically, home visiting programs and quality home- or center-based child care help promote healthy child development, early learning, and strengthen the social network for children and their parents. Independently, however, each of these service delivery systems may struggle to move the needle on important factors that effect real change for families in our communities.

What if we took a unique approach to deliver integrated care using Children’s Hospital of Philadelphia (CHOP) as an anchor institution alongside community partners to achieve real results? Would we be able to create efficiencies and reduce burden for providers? Most importantly, would we be able to more adequately meet the needs of our patients and families?

We think so.

Removing Barriers to Provide the Best Quality Care

For 11 years prior to my arrival at PolicyLab, I worked for the Nurse-Family Partnership (NFP) National Service Office, a national non-profit organization that replicates and sustains an evidence-based home visiting model of care to improve maternal and child health and well-being for first-time pregnant women and their children. Because of the model’s proven and long-term health-related benefits to patients, NFP prioritized “integrating” its home visiting model within health systems.

For years I worked to cultivate relationships, identify opportunities for integration and attempt to bring them to fruition. Despite what seemed like heroic efforts, we never got past envisioning integration beyond a co-located model—a now widespread model of care that features a physical co-location of home visiting services with health care providers under one roof. While this model offers opportunities for improved access to and coordination of services, alone co-location does not facilitate information sharing within the group of health care professionals that make up the clinical care teams.

As the investment in home visiting has risen, so too has the reliance on these services to address some of society’s most complex and pressing issues—parental mental health, intimate partner violence, child abuse and substance use. As I navigate conversations with state partners and governmental officials, I impress upon them that while home visitors are indeed experts in their field with the ability to incite meaningful change, we cannot rely on them alone to deliver broader systemic changes. The same stands true for pediatricians, child care professionals and teachers. If we want to see real change, we must create a system where we can work smarter together. A coordinated approach between the many people and services that have touchpoints with families will afford us the opportunity to have maximum impact within our communities. 

So, we asked ourselves—what if we worked smarter together, not harder independently, to impact child health?

Building a More Coordinated Community

This vision inspired our team to build a new strategy to help children thrive. As the state’s lead evaluators for home visiting services with intimate knowledge of the system, and as an organization primarily made up of pediatric clinician-researchers, PolicyLab recognizes that each system has unique skills and abilities to improve children’s health and well-being. This collective experience led us to develop the Community-Clinical Systems Integration (CSSI) initiative. As part of this new project, which is launching today, PolicyLab will work with partners from CHOP’s Cobbs Creek primary care practice, child care experts and a local evidence-based home visiting program to create an intentionally integrated and coordinated system of care. Our objective is to identify areas of alignment between systems that create efficiencies and reduce burden on providers, enhance coordination of care for patients and improve sustainability of high-quality services.

Here’s how it works: Public health nurse home visitors will continue to see patients in their homes. Through a shared staff model, nurse home visitors will participate on the patient’s medical team, actively communicating with the child’s pediatrician. This alignment and ongoing communication directly between providers and nurse home visitors will enhance support provided by the full patient care team. Through this integrated approach, the team will effectively and efficiently deliver services to families. The model will also ensure that efforts are not duplicated, but rather delivered in a way that utilizes providers’ skill sets most appropriately, while adequately addressing the needs of families. Over the course of this three-year pilot program, we’ll evaluate its impact and hope to expand its reach in the future.

There is no doubt that the many systems surrounding children and caregivers are doing the best they can to deliver quality care and services. But now more than ever, when time and resources are limited, we are called on to be more thoughtful about how we provide the best possible care to patients and their families. Together, we can achieve true systemic change that will allow each child to thrive and live a healthy life.