P2.060: HealthySteps, Big Leaps: Advancing Care for Children with Medical Complexity

Background: Children with medical complexity (CMC) experience significant health challenges due to multiple chronic conditions, functional limitations, and frequent healthcare needs. Their families often require coordinated support across medical, developmental, and social domains. Traditional systems can be fragmented, placing a heavy burden on caregivers. At the University of South Florida (USF), our pediatric complex care program uses a medical home model to provide comprehensive, family-centered care.

Project Description: To enhance advocacy and support for families of CMC, our program integrated HealthySteps Hillsborough (HSH) into medical home visits. HSH is a national nonprofit program dedicated to enhancing the well-being of children aged 0–3 years by identifying needs and linking families to essential resources. Funded by the Children's Services Council (CSC), HSH operates within a tiered model to ensure all families receive the support they need. Additionally, the program provides resources through Administrative Service Organization (ASO) funds from the Hillsborough County Children’s Board. This partnership offers caregivers real-time access to developmental screening, mental health support, and referrals to community services. Between October 1, 2023, and September 30, 2024, HSH engaged 321 participants in our pediatric complex care program, enrolling 81 new children and 73 caregivers. 167 of these participants received follow-up evaluations from prior year enrollment. 85 families were connected to community services, utilizing $1,377.06 in ASO funds for essential needs including portable cribs, diapers, transportation, health insurance navigation, and postpartum resources. Regarding postpartum resources, 10 caregivers were referred for external mental health support, with 7 successfully connected to long-term services. HSH also facilitated 47 early intervention referrals following developmental screening and provided Safe Baby education to 89 caregivers with infants under one year to help prevent infant injuries.

Discussion: CMC and their families require heightened support, relying on comprehensive care that addresses their medical, developmental, and social needs. With approximately 65% of our CMC population under age 3, HSH can play a pivotal role in our program. ASO funds serve as a tangible expression of community support, directly benefiting participants. Notably, about 20% of ASO funds across the USF pediatrics department were allocated to CMC families, underscoring their significant need. By integrating HSH into our pediatric complex care medical home model, we remove barriers to essential services, alleviate caregiver burdens, and empower families to better support their child’s health and development.

Conclusion: This integrated advocacy initiative demonstrates a novel and effective approach to promoting child health by addressing the multifaceted needs of families with CMC. Few pediatric complex care programs nationally have adopted this model, highlighting its innovation and potential for replication. By embedding advocacy into routine care, we promote equity, early intervention, and caregiver well-being, which are foundational in advancing health outcomes for CMC.