Connecting the Medical Home and the Community: Needed by Families Now More Than Ever

In recent years, the Center for the Study of Social Policy has engaged with national partners and local communities to develop innovative ways of improving services for the youngest children (0-3). We see this work as central to achieving our mission of achieving a racially, economically, and socially just society for the health and well-being of all children and families. Importantly, the work involves expanded coordination and linkages necessary for the development of local early childhood systems and services that connect the health care sector to other services and supports for families. There has never been a greater urgency for this type of effort as the inadequacy of our safety net for families has been made even more apparent by the COVID-19 epidemic.1 The epidemic is laying bare our country’s entrenched systemic inequities in income, housing, and education that have long contributed to the disparities in health outcomes and the well-being of young children of color, which will now most likely worsen.2 

An equity-driven, family-centered community health system (FCCHS) can help respond to the added stressors that families are encountering by providing them with the opportunities, supports, and resources families need and deserve to thrive.3 The elements of the FCCHS include:

  • A focus on population health with disaggregated data that informs local decision-making;
  • A local, coordinated early childhood system that works collectively to dismantle structural inequities and racism;
  • High-performing medical homes that better support families and that connect them with the array of community supports to address family needs;  
  • Parent leadership networks that hold the programs, services, and community systems accountable;
  • Vibrant and robust community networks that create the supportive relationships for healthy outcomes of positive experiences (HOPE); and
  • All-in strategies for newborns and their families that support their foundational relationships for improved life course outcomes.

Coordinated within communities, this approach fuses several transformational elements into a more comprehensive, science-informed, and effective response to children’s and families’ growing needs and risks. Creating a family-centered community health system requires effective partnerships between early childhood systems, pediatric primary care providers, and family leaders. Each element of such a system enhancement is needed now to address the challenges that families face from COVID-19 crisis.

Pediatric primary care is a nearly universal access point for families, whether provided in person or now by telemedicine and careful in-office visits. To optimize child and family health and well-being, pediatric providers need to be able to respond to families’ immediate expressed needs which often now include the urgent need for connections to other services and supports in the local community, due to loss of jobs, income, and daily food and living supplies. What do we know about pulling these pieces together into a unified family-centered community health system? The Center for the Study of Social Policy’s report for the Pediatrics Supporting Parents (PSP) Initiative, Fostering Social and Emotional Health through Pediatric Primary Care: Common Threads to Transform Everyday Practice and Systems identifies common practices and models of care from across the country that can guide us in developing such a system.4 These practices demonstrate three actions that pediatric primary care providers can take to respond to the comprehensive needs that families are facing and that enhance child social emotional development: (1) nurture parents’ competence and confidence; (2) connect families to additional supports to promote healthy social and emotional child development and address family stressors; and (3) develop the care team and clinical infrastructure to support this work. Across all the common practices, strong, strengths-based, trusting, and humble relationships among and between parents, the health care team, and the community are essential for promoting the health and well-being of young children. These important practices identified in the PSP Initiative carry even more weight during the COVID-19 crisis. Many of these activities can be accomplished through telehealth virtual visits between primary care providers and families. The pediatric health care team can assist families who are sheltering in place without childcare, and anxious about the health, social, and economic impact of the pandemic. Providers can and should  focus on more than a physical exam and immunizations to provide greater support to the urgent needs of families in this time of crisis.

We thus need more high performing medical homes.5 More team-based, relational, and community-linked primary care approaches can increase the capacity of a medical home to serve families with young children and coordinate with the local community. High performing medical homes focus on both bio-medical and social determinants of health. They aim to promote well-being and build on family strengths, address needs, and promote parental well-being and resiliency, and positive parenting, often reflecting protective factors as described in the Strengthening Families Protective Factors Framework.6 They provide well-child visits that go beyond physical exams and immunizations and incorporate a focus on parent-child relational needs. And with expanded care coordination within the high performing medical home, families are engaged ever more personally, relationally, to meet their specific needs. In addition, they integrate or link to other services such as family support, Help Me Grow, and developmental services, mental health services, and home visiting, that are ever more important during times of stress.  

We have seen the contribution that exemplars of high-performing medical homes and pediatric care models are making. Efforts such as DULCE or HealthySteps; universal promotion activities, like Reach Out and Read or Promoting First Relationships in Pediatric Primary Care; and/or early relational health monitoring and interventions, like the Welch Emotional Connection Scale, Video Interaction Project, or Early Relational Health video monitoring and feedback all provide examples of how to respond comprehensively to the myriad of needs that families are facing and how to support the social and emotional health of young children and their families.

It is time for Medicaid to advance and support these proven service delivery models to meet the urgent needs facing families including helping them access necessary resources, build resiliency, and strengthen the caregiver-child bond. Intensifying efforts in this moment of the epidemic crisis could help meet immediate needs as well as address the longer-term needs of community rebuilding and family recovery. Advancing the high performing medical home within an increasingly needed family-centered community health system can help and may perhaps even foreshadow a critical strengthened safety net for families.  Such restructuring may bring us closer to the standard of care that families with young children have always needed yet seemingly intractable barriers have prevented us from achieving at scale. Perhaps now is the moment.


1 Bachireddy C, Chen C, Dar M. Securing the Safety Net and Protecting Public Health During a Pandemic: Medicaid’s Response to COVID-19. JAMA. 2020.

2 Meltzer J. COVID-19: Exposing the Racial Fault Lines in Our Public Policies. In. Washington, DC, 2020.

3 Willis D. Advancing a Family-Centered Community Health System: A Community Agenda focused on Pediatrics, Early Relationships, and Equity, Washington, DC: Center for the Study of Social Policy; 2019.

4 Doyle S, Chavez, S., Cohen, S., and Morrison, S. Fostering Social and Emotional Health Through Pediatric Primary Care: Common Threads to Transform Practice and Systems. Washington, DC: Center for the Study of Social Policy; 2019.

5 Johnson K, & Bruner, C. A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health. Child and Policy Family Policy; 2018.

6 Harper Browne C. The Strengthening Families Approach and Protective Factors Framework: Branching out and reaching deeper. Washington, DC: Center for the Study of Social Policy; 2014.