Developmental Understanding and Legal Collaboration for Everyone (DULCE) is a universal, evidence-based pediatric care innovation that addresses the social determinants of health and supports early relational health for families with infants in communities that are under-resourced and have been marginalized by racist systems. Family Specialists have played a leading role in pivoting DULCE’s response to the urgent needs of families during the pandemic. This blog provides a brief background of DULCE, the DULCE Interdisciplinary Team, and its ability to support infants and their families.
Family Specialists are Community Health Workers (CHWs)—frontline public health practitioners who are trusted members of and/or have a close understanding of communities. They are connectors between the health system and community to support a broad range of needs.1 With approximately 59,000 employed CHWs nationally as of 2019,2 they encompass a variety of professionals, including outreach educators, community health representatives, and promotores de salud (health promoters). While CHWs generally support communities in the navigation of the health system through assistance, capacity building, and advocacy,3 the function of their roles differs. They may hold workshops educating the Latinx community on cervical cancer, provide enhanced asthma care through case management and home visiting services for Black and Latinx children, or even increase the influenza vaccinations on college campuses through peer outreach.4,5,6 Given the broad scope for CHWs, DULCE provides an approach for a specialized CHW in the pediatric setting known as a Family Specialist.
The responsibility of the DULCE Family Specialist is supported through a strong collaborative relationship between early childhood, health, and legal systems. Through a partnership with families and the medical provider, the Family Specialist joins well-child visits during the first six months of an infant’s life. They support families during and in between these routine visits to create a relational context to understand family needs and help strengthen family life, which include identifying concrete support and mental health needs. As part of a broader team of experts known as the Interdisciplinary Team, the Family Specialist joins medical providers and partners from early childhood and public interest law systems. The team works to address socio-economic stressors through weekly case review meetings. The Family Specialist then partners with families to identify and connect with supportive resources and services. In subsequent encounters, the Family Specialist finds out about their experience with the service and provides additional assistance where needed. Any barriers identified by the family are addressed with the Interdisciplinary Team. Through this unique collaboration with families and three sectors, the Family Specialist can address the needs of families with infants.
The Family Specialist plays a key role in DULCE by developing and leveraging relationships to positively impact families, clinics, and communities. Family Specialists can quickly develop relationships with families given shared experiential, cultural, linguistic, and/or racial/ethnic backgrounds. The durability of this relationship is supported by their training in Touchpoints and ongoing connection with families during and between routine visits. Family Specialists on average connect with DULCE families 11 times during the six-month approach. The high touch nature of the role provides the Family Specialist and, by extension, the health system an understanding of social and economic stressors that better positions the pediatric medical home7 to address families’ needs.
The partnership between the Family Specialist and the Interdisciplinary Team allows for problem solving by utilizing a multi-sector brain trust to address barriers to resources and support referrals. For example, as fear and uncertainty around a proposed and later finalized public charge rule grew, Family Specialists heard about families’ fear of applying for benefits. Through Family Specialist insights and the expertise of the DULCE legal partner, Family Specialists were equipped with accurate information about the rule and specifics around benefits families can or cannot access, later relayed to families. If a legal concern arose for a specific family, the Family Specialist may facilitate a referral to the DULCE legal partner. Given the harvested information from Family Specialists on family needs, coupled with the team-based approach to addressing barriers, the pediatric medical home is primed to systematically identify patterns and gaps in the resource and service landscape that might otherwise go unnoticed – providing opportunities for local advocacy. Family Specialists enhance pediatric care by serving as the conduit between families and the medical home.
As pediatric clinics nationally struggle to engage families and address heightened needs during this pandemic, DULCE Family Specialists were positioned to respond to those changing needs. Family Specialists transitioned to working virtually with families, continued to develop relationships with them, and served as a support during this time of isolation while also assessing socio economic needs. With the support of the Interdisciplinary Team that now also meets virtually, family needs are addressed through collaborative problem solving to ensure that access to services and supports continues.
Given the current climate, many DULCE Family Specialists are connecting with community-serving organizations before making referrals, ensuring they are open and have the capacity to assist DULCE families. These inquiries have resulted in a menu of local services and resources that the pediatric medical home can leverage for all families. Importantly, given how quickly policies and guidelines continue to change in this landscape, the partnership between the family, Family Specialist, and legal partner is helpful in sharing knowledge, understanding eligibility requirements, and supporting families in completing applications for benefits or services. For example, a Family Specialist has been working to support families who are undocumented in accessing cash aid through a COVID-19 related program in California. Given the newness of the program and high demand, the Family Specialist leaned into their relationship with the legal partner to support families applying for and accessing the cash aid. By leveraging the relationships developed between families, the Family Specialist, the Interdisciplinary Team, and community organizations, DULCE clinics can address challenges families face in the midst of the current pandemic.
Decades of research has shown the positive value and impact of CHWs. 8,9,10 Recently, a coalition of health organizations issued a call to action asking Congress and the Centers for Medicare & Medicaid Services to develop a set of solutions to support the funding of CHWs. 11 Despite having years of evidence, there are few funding mechanisms to ensure their sustainability, with many CHWs being paid by piecing together several sources of funding, which often typically include time-limited short-term grants and philanthropic funds. In DULCE, for example, there are a variety of ways communities have leveraged different funding opportunities. Some sites rely on grant funding that is augmented using local resources, others have tapped into Delivery Service Reform dollars through their state’s Accountable Care Organization, and one site has leveraged Inter-Governmental Transfers. Changes to Medicaid rules are one likely route for regular, sustainable funding. Currently, Medicaid can be used to fund only a narrow range of services classified as preventative, and only if a state has had a Preventative Services Plan Amendment (SPA) approved.12,13 With increased interest in exploring how CHWs can support the public health response to COVID-19,14,15 conversations around financing have resurfaced.16 As the health system seeks ways to address the needs of families, particularly of those in under-resourced localities, CHWs can serve an important role if there are financing solutions to ensure their sustainability. For DULCE, the sustainability of the Family Specialist is critical in providing access to quality, holistic care to families of low-income backgrounds and to communities of color during and beyond this pandemic.
As many search for ways to address the challenges of the moment, DULCE is a reminder that CHWs are a piece of the puzzle. Family Specialists can play an important role during this pandemic and as we reimagine pediatric care for the future. They are critical to the health system workforce and their sustainability is imperative. By ensuring appropriate funding pathways, we move closer to the promise of a racially, economically, and socially just society in which all families and children thrive.
- E. Lee Rosenthal, A Summary of the National Community Health Advisor Study. University of Arizona Health Sciences Center (June 1998).
- O’Brien, M. et al, Community Health Worker Intervention to Decrease Cervical Cancer Disparities in Hispanic Women. Journal of General Internal Medicine. 2010, 25 (11): 1186-1192.
- Wood, E. et al, Community Asthma Initiative to Improve Health Outcomes and Reduce Disparities Among Children with Asthma. MMWR Suppl. 2016, 65 (1):11-20.
- Huang, J. et al, Community Health Workers on a College Campus: Effects on Influenza Vaccination. Journal of American College Health. 2018, 66 (4): 317-323.
- 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.
- Perry, H. A Brief History of Community Health Worker Programs. USAID Maternal and Child Health Integrated Program. 2013.
- Swider, S.M. Outcome Effectiveness of Community Health Workers: An Integrative Literature Review. Public Health Nursing. 2002, 19 (1): 11-20.
- E. Lee Rosenthal, et al, Community Health Workers: Part Of The Solution. Health Affairs (July 2010)
- Ellen Albritton, How States Can Fund Community Health Workers through Medicaid to Improve People’s Health, Decrease Costs, and Reduce Disparities. Families USA (July 2016).
- Denise Smith and Ashley Wennerstrom, To Strengthen The Public Health Response To COVID-19, We Need Community Health Workers. Health Affairs (May 6, 2020).
- Rob Waters, Could Community Health Workers and Promotores de Salud Help California Respond to COVID-19? California Health Care Foundation (June 4, 2020).
- Shreya Kangovi, To Protect Public Health During And After The Pandemic, We Need A New Approach To Financing Community Health Workers. Health Affairs (June 5, 2020).