P2.129: Embedding Community Health Workers into the Pediatric Medical Home to advance Early Relational Health and flourishing families

Background: Our team of CHWs accompany families in the way modeled and implemented by Dr Paul Farmer who was a global public health pioneer. Farmer and his colleagues effectively created community-based treatment strategies to deliver high-quality health care in resource-poor settings such as Rwanda. We have built a model that mirrors what Dr. Farmer sought and successfully created through the power of accompaniment from the CHWs to our patients and families from the beginning (the newborn visit).

Project Description: We are cognizant that this is a personal journey and that our team of CHWs are at the heart of the relational workforce and care coordination at our practice. Our team of CHWs have an integral role on our care team and participate in interdisciplinary team meetings to collaborate and co-learn. We see this team of CHWs collaborating with the entire clinic care team in order to reduce silos and offer system navigation and accompaniment. Workflows are outlined to assess for social determinants/drivers of health at the clinic and connection to needed resources and services for health-related social needs. CHWs will also maintain relationships with service providers in the community and remain updated on what services and openings there are in the community to assist patients. Our team of CHWs will be central to the workflows to address any barriers to families getting care and/or their appointments and connect them to resources for barrier reduction. Not infrequently they attend IEP and other community-based meetings or support groups alongside families. They provide families we serve with developmentally appropriate education on their health needs and wellness in order to support skill development and sustain their wellness and self-management ongoing. Our team of CHWs participates in professional development on topics such as trauma informed care, strength-based care, solution focused counseling, motivational interviewing, and cultural sensitivity.  All have completed trainings in Promoting First Relationships and Reach Out and Read.

Discussion: Recognizing that ~20% of what Pediatricians do is strictly medical, effective teams of care are needed in order to share care, screen for unmet social needs, and provide the right resources, at the right time, in real time.

Conclusion: Community Health Workers build family resilience and connection, early relational health and positive childhood experiences, and promote flourishing even amid high adversity. Child flourishing strongly predicts social-emotional wellbeing, school readiness and engagement, and positive mental health. This is done by co-creation with families, supporting families from the start, and understanding and enhancing teams of care, all contribute to a high performing medical home that promotes Early Relational Health and optimal development