PolicyLab

Caregiver well-being can greatly influence children's health, especially during a child's earliest years. Nurturing caregiver-child relationships fosters resilience while mitigating the impact of adverse events. This is why child health experts have encouraged—and some organizations have adopted—models to support caregivers in pediatric primary care. 

This National Family Caregivers Month, we'll examine two primary care models that support caregiver-young child health as a unit, also known as dyad care or dyadic care. We'll offer suggestions for overcoming the barriers that health systems face in implementing these models, and share policies that have helped to scale dyad care. 

Meeting Families Where They Are 

Following a child’s birth, caregivers and children have high health care needs and known gaps in preventive care. That’s why it is critical for pediatric providers to use each existing touchpoint with families to provide comprehensive services. There are 10 preventive care visits recommended for children in their first 2 years of life—and caregivers are more likely to attend these than visits for themselves. The following dyad models build on this opportunity. 

HealthySteps is an evidence-based model for providing dyad care. It brings a child development expert—often a licensed behavioral health professional—into the pediatric primary care team to promote healthy relationships, foster positive parenting, strengthen early social and emotional development, and ensure access to services that address both child and family needs. PolicyLab is currently implementing and evaluating HealthySteps and identifying strategies to promote long-term funding sustainability. 

The IMPLICIT Network is a second dyad care model. It integrates screening for common maternal health care needs into pediatric well visits. IMPLICIT focuses on maternal depression, tobacco use, contraceptive needs and multivitamin supplementation. Some IMPLICIT practices have developed strategies to respond to caregiver needs at the point-of-service, for example by working with behavioral health teams integrated into primary care sites or by connecting caregivers to additional health care resources outside of the visit. Research on the model to date has highlighted its utility in assessing and addressing behavioral risks for future poor birth outcomes, but more research is needed on outcomes. 

Addressing Barriers to Scaling Dyad Care  

HealthySteps and IMPLICIT are two very different programs. But they face similar barriers as they attempt to integrate and streamline care for families. In a recent study, I (Emily) explored some of these barriers. 

Payment  

Current health care payment structures do not sustainably fund preventive dyad care models in pediatric primary care. Without funding, health care providers are limited in their ability to offer these services. For the potential of dyad care to come to fruition, payment reform is required, particularly in Medicaid and the Children's Health Insurance Program (CHIP). 

At least three issues arise in considering payment for dyad models of care: 

• Some dyad models, such as HealthySteps, incorporate new team members into pediatric primary care visits. Billing practices must be flexible enough to allow teams to incorporate community health workers, care coordinators, integrated behavioral health providers or other related team members with the skills to meet family needs.
• Pediatric primary care sites should be able to bill directly for some limited maternal services. This may require expanding the types of services that payers allow pediatric health care sites to provide for adults. PolicyLab has explored this related to postpartum mental health and caregiver access to treatment. In addition, parents should be able to receive some services from their child’s health care team while also maintaining their own separate primary care relationships, if desired.
• As we’ve previously discussed, children should be able to access behavioral health services without needing a behavioral health diagnosis. 

Communication among care teams 

To safely use all touchpoints with families, health systems and public health agencies need better strategies to share information about family care needs. 

Technology enables communication across care settings to improve care for individuals. For example, health information exchanges, remote monitoring programs, and vaccine documentation systems all ensure that relevant health information can be documented and viewed by multiple care teams.  

These systems could be adapted to improve communication between pediatric and maternal care teams, with appropriate privacy safeguards. One example of innovation in documentation sharing to improve communication is a PolicyLab-led initiative that advances data integration between pediatric primary care and nurse home visitors. Facilitated by the electronic health record, this model offers bi-directional communication between providers to ensure that families have consistent, cohesive support, and that systems avoid duplicating services or working at cross purposes. 

Privacy 

As dyad care models expand, some families or individuals may have particular preferences for how and what information is shared across teams—as we’ve seen in our work on health-related social needs. Additional work may be required to establish areas of sensitivity. Ensuring these preferences can be identified and respected could help promote positive relationships between families, health care teams and other service providers. 

Policies and Programs That Are Leading the Way 

Across the country, we’re seeing state, local, and health system-led initiatives seek to address these barriers. The enactment of California Medicaid’s dyadic benefits, Massachusetts’ alternative payment model, and enhanced payment models in states like Arkansas have created sustainable environments for dyad care models.  

Following guidance issued in 2016 by the Centers for Medicare & Medicaid Services, most state Medicaid programs reimburse for caregiver depression screenings in well-child visits. A recent study found that Colorado’s Medicaid reimbursement is associated with increased outpatient mental health treatment for mothers, providing evidence that payment reform improved access to needed services.

Technology is essential for enhancing communication, streamlining processes, and reducing burden, but we must never lose sight of the importance of trust and human connection in delivering quality care. We’ve previously discussed innovative health care initiatives designed to strengthen coordination among care team members, including our own integration strategy for nurse-led home visiting services and pediatric primary care. Nurse home visitors, who hold high levels of trust with families, have historically been siloed from the broader care team. With the help of technology and access to the electronic health record, communication has improved, and the trust families place in their home visitor is now extended across the entire care team.    

Caregiving is a beautiful challenge. Policymakers, health care payers, and health care providers can lighten the load—and promote kids' long-term health—by enabling the growth of dyad care.