Implementation Strategies for Early Childhood Care Coordination and Linkage in Community Health Centers
This webinar focuses on applying implementation strategies for early childhood development care coordination and linkage for patients 0-5 in community health centers.
The Early Childhood Developmental Health Systems (ECDHS): Evidence to Impact Center hosted a webinar focusing on implementation strategies for early childhood development (ECD) care coordination and linkage in community health centers. The webinar was held with representatives from 151 health centers funded by the Health Resources and Services Administration (HRSA) to improve developmental outcomes among children ages 0-5 through increased screenings and follow-up services.
In this webinar, Dr. Marian Earls, developmental-behavioral pediatrician, and Dr. Liz Isakson, executive director for Docs for Tots – along with experts from the American Academy of Pediatrics and Help Me Grow National Center – shares stories from the field, community health center approaches, overview of resources, and tests of change opportunities to help health center attendees and viewers:
- Identify at least one strategy to support ECD referral and follow-up.
- Recognize strategies to establish relationships with referral agencies.
- Describe communication feedback loops so children and their families can access ECD services.
Key Takeaways
- Team-directed care helps improve care through population management, increase efficiency, strengthen family relationships, and engage family leaders.
- Bailit and value-based payment supports implementing risk-based pediatric screening, interventions, robust linkages, and referrals.
- Risk stratification helps assure team continuity for well-child appointments, gives extra time to schedule appointments, enhances pre-visit planning and care coordination, facilitates tracking outcomes, and helps families feel heard and understood.
- Referral and linkage require partnering with networks outside of the health center to link to health, education, and social support systems. It is important to think about the different types of connections for families, including community-based supports, early intervention, sub-specialty care, and child care. Many communities have existing referral networks, lists, and coalitions that can support connections.
- Referral and linkage take time and a team to move into territory outside of the health center, and the work is not linear. Building a continuum of care means building solid, longstanding relationships across providers that touch the lives of families with young children.
- Community partnership is a two-way street and helps ensure stable, relationship-based referrals for families. Health centers do not “have to go it alone” when building community partnerships – there are existing resources, services, and systems.
Possible Tests of Change for Health Centers
To Facilitate Care Coordination and Linkage
- Use a “flag” – like a sticky note in Epic – for scheduling early morning visits or longer visits.
- Enhance pre-visit planning.
- Implement protocols like morning huddle discussions.
- Integrate with behavioral/mental health specialists, social workers, and family navigators.
- Optimize billing and coding.
To Establish Relationships With Referral Networks and Create Communication Feedback Loops
- Establish a referral pathway with a community partner and test the feedback loop to ensure both sides are sharing and receiving information as planned.
- Elicit feedback from families and referral partners on the quality of the referral.
- Create a regular quality improvement meeting with referral partners to walk through case examples and determine opportunities for improvement.
Featured Speakers
Liz Isakson, MD, FAAP
Executive Director, Docs for Tots, Pediatrician
Marian Earls, MD, MTS, FAAP
Board-Certified, General Pediatrics, Developmental and Behavioral Pediatrics
