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Community Clinical Systems Integration Initiative – Home Visiting

Statement of Problem

A growing body of research links social and environmental factors facing communities directly to a multitude of health inequities. Fragmented and siloed community supports and health delivery systems further complicate and add to the complexities that families face when navigating services. Integrating health care with that of community maternal and child home visiting services is a promising strategy to re-envision preventive care in a way that holistically and intentionally approaches a family’s care and improves health outcomes across diverse populations. The benefits of evidence-based home visiting have been well-documented and include improvements in parenting approaches, family well-being, preventive health care engagement and connection to social resources. 

Despite increasing interest by policymakers in deploying home visiting solutions for families of young children, realizing the maximum potential of these services requires systems-level change to bridge these community-based preventive services with care provided in a clinical setting. While a call for uniting these services has been raised by maternal and child health leadership, actual efforts to meaningfully re-envision service delivery to communities have been limited. 


Next Steps

While we have experienced considerable progress, full integration of home visitor care within the clinical care setting rests on the ability to avoid duplicative services and reallocate resources in ways that provide the best care for families. CCSI continues to work towards the creation of an uninterrupted primary care experience for families with fluid communication between all parties (including the patient), as well as aligned billing, documentation, finances and workflows. 

As we continue to develop this integrated model of care, we aim to:

  • Continue to refine the staffing model shared between family home visiting programs and pediatric primary care and expand to a second community-based provider to serve more children in the Philadelphia community.
  • Improve efficiencies in documentation and communication workflows to enhance patient and provider experience and outcomes.
  • Continue to evaluate the incremental value of this integrated staffing model on child health outcomes and utilization.
  • Disseminate research findings and best practice recommendations for home visitor integration of community practice and primary care.
  • Collaborate with other health systems to identify opportunities that support replication of the model beyond one health system.
  • Investigate and develop a financial model that generates a sustainable path for CCSI efforts.

This project page was last updated in July 2024. 

Suggested Citation

Children's Hospital of Philadelphia, PolicyLab. Community Clinical Systems Integration Initiative – Home Visiting  [Online] Available at: [Accessed: plug in date accessed here].