Advancing Early Relational Health in Child Health and Communities: Opportunities for Medicaid Support

In June 2019, as part of the Pediatrics Supporting Parents initiative, CSSP and our colleagues at Manatt Health released Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change.  Designed as a practical guide for policymakers, program administrators, managed care plans, pediatric care providers, advocates and others, the Blueprint features key strategies  and tools for optimizing the use of Medicaid and CHIP to help ensure that the well-child care delivered to young children promotes and strengthens early parent-caregiver relationships and healthy development that lead to school readiness and future success. Given that nearly half of young children in the U.S. are covered under Medicaid and CHIP, these programs have a central role to play in supporting children, families and pediatric care providers and in sparking innovation in the field.  

As we work to share and highlight the Blueprint, we have invited partners across the country to share their perspectives and experiences implementing strategies presented in the Blueprint, as well as offer new ideas and tools for using Medicaid and CHIP to advance action. Today’s blogpost is from David Willis, Senior Fellow at CSSP.  We thank him for this valued contribution.

Early relational health (ERH) is a dynamic concept that has emerged in the last few years from leaders in pediatrics, public health, early childhood mental health, and child health policy. ERH elevates the primacy of the earliest relational experiences and interactions between infants and their caregivers that builds the foundations for health, learning, and social well-being. It is multidimensional, building on interdisciplinary research from the fields of child development, social-emotional development, infant mental health, parent-infant observations, neurodevelopment, interpersonal neurobiology, resilience, and trauma.

We define ERH as the complex interpersonal interactions between young children (birth to age 3) and their parents, extended family, and caregivers, which can have positive impact on a child’s healthy development. This is not about judging or training parenting, but rather recognizing, supporting, and strengthening the emergent development of all early caregiver childhood relationships. In brief, the key elements within the dynamic concept of ERH are: 1) maternal and family well-being; 2) positive, attuned, and nurturing caregiver-child relationships; 3) a focus on resiliency in the face of trauma; 4) an explicit effort to advance equity, family engagement, and social supports; and 5) a paradigm shift in early childhood to improve child and family health, development, and well-being through the focus on relationships.  

Further, as the ERH concept becomes more visible and salient, the early childhood system-building efforts in communities can align the relational focus across all sectors including pediatric health care, public health services, early care and education, child welfare, and family support services (including home visiting and others). ERH embodies principles and characteristics of equity, culture, and family voice and is bi-directional and multi-generationally focused and foundational for future health, early learning, and social-emotional well-being.

Activities are underway in the testing and development of ERH tools, practices, indicators, and measures, knowing that advancing ERH requires careful attention to impact as well as caution about bringing one more new activity to the medical home which is already over-burdened. By engaging strategic partners in authentic dialogue, we hope to enrich the development and ongoing spread of relational tools and practices that are practical, scalable, and adaptable across child and family health systems, the early childhood communities, and maternal-child health.

Clearly, the simultaneous development of sustainable financing strategies is critical for advancing early relational health activities and practices within the child health system. Given that the child health sector is the access point for all young children and families, and especially for those children and families in communities of greatest need, it is important to engage Medicaid transformation in these efforts. The work of advancing ERH is cross-cutting with the potential of transforming pediatric practices for young children and families and improving health and developmental outcomes for children and families. Many of the activities and strategies articulated in CSSP’s new report Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change are directly applicable to ERH efforts. Here are some of the current activities and corresponding programs that are within the ERH construct, many of which were noted in the Blueprint:

  • The training of child health practitioners on promoting an expanded early relational health (Promoting First Relationships, Facilitating Attuned Interactions in Pediatrics);
  • Screening approaches that leverage objective tools for development, maternal depression, trauma, and social drivers of health (SDOH);
  • Advanced medical home activities that enhance parent-child interactions and child development (Reach Out and Read, Developmental Understanding and Legal Collaboration for Everyone [DULCE], Healthy Steps, Welch Emotional Connection Screen [WECS], etc.);
  • Co-located mental health services that provide parent-child interaction teaching, prevention, and early interventions (co-locating early childhood mental health practitioners, Video Interaction Project, Early Relational Health Screening and Feedback, etc.); and
  • Care coordination and case management with expanded bi-directional linkage and coordination with local community efforts that focus to strengthen the family and early relational development (home visiting, Early Head Start, parent education and family support programs, etc.).  

Many of the above activities can be or are currently supported by Medicaid and Medicaid EPSDT policy and may meet many of the requirements of high quality and advanced medical homes. As reliable, practical, and scalable early relational health indicators and measures are developed, population health management, value-based payment structures, and risk management approaches may demonstrate the impacts of an early relational health approach.