Description

Pierce County embedded Community Health Workers (CHWs) into pediatric primary care to address unmet social needs and improve relational health.

This approach was Inspired by Dr. Paul Farmer’s model of accompaniment, which Dr. Farmer describes this way:

“To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end…There’s an element of mystery and openness….I’ll share your fate for awhile, and by ‘awhile’ I don’t mean ‘a little while.’ Accompaniment is much more often about sticking with a task until it’s deemed completed by the person or person being accompanied, rather than by the accompanier.”

CHWs journey with families according to their expressed needs, rather than a timeline determined by the practice. CHWs assess unmet social health needs and are introduced as a member of the care team from the beginning at the newborn visit. They are specially trained in early relational health practices and frameworks.

Need / Problem Statement

Only 20–30% of pediatric work is strictly medical; the remainder involves social health needs.

Families often face isolation, lack of peer/community support, and barriers to resources — all of which heighten parental stress and postnatal mortality risks. The traditional RVU-based payment system, which determines compensation based on volume of work and level of effort expended in treating patients, undervalues team-based care. This creates a mismatch between what families need and what the system delivers. Healthcare systems are in their ‘infancy’ in recognizing (financially and otherwise) that team-based care is more effective for families and an antidote to the rampant burnout and moral injury for clinicians and staff in primary care and beyond.

Process

The Washington Chapter of the American Academy of Pediatrics (WCAAP) led the advocacy for Medicaid coverage of CHWs for relational health.

Pediatrics Northwest convened the First-Year Families Steering Committee in 2020, with approximately 30 stakeholders including parents, to design new staffing models and closed-loop referrals. Parents emphasized the importance of peer support at the pediatric medical home, which became a cornerstone of the model. The WCAAP advanced Medicaid coverage and equity goals, the steering committee defined goals and strategies, including systemic racism mitigation, while family leaders noted that peer support is vital which shaped pilot design.

Partnership

Family voices were central from the outset.

Two parent leaders on the steering committee elevated the need for peer support to policymakers. Their advocacy contributed to state legislation funding 50 CHWs in pediatric primary care beginning in 2023. The Governor’s office, legislators, and Department of Health staff supported the effort, which led to Medicaid billing approval by July 2025. Parents co-designed workflows and screening practices, legislative champions advanced CHW funding, and partnerships expanded to include WCAAP, state agencies, and community partners.

Implementation

Implementation began with behavioral health integration at Pediatrics Northwest in 2019 and the rest of the timeline is as follows:

• 2019–2021: CHW program manager hired, groundwork laid
• 2022: First CHWs hired for perinatal-to-five relational health and K-12 mental health
• 2023: Funding expanded team with six additional CHWs
• 2024: Centers for Medicare & Medicaid Services (CMS) approved CHW Medicaid State Plan Amendment
• 2025: CHWs began billing Medicaid for services (person-centered planning, care coordination, navigation, behavior change, and health education)

Key data points proved to be game-changing. (e.g., “It took 26 phone calls for a family in Washington to secure one mental health appointment for their child, with a waiting period of three to six months”). Opportunities for dialogue (lunch-and-learns, team meetings) helped convince skeptics. Over time, trust and co-ownership grew.

Changes & Outcomes

The CHW program has transformed family engagement and outcomes in the following ways:

• Social health needs are addressed at the right time, in real-time
• Policies/workflows are improved (e.g., missed appointment policy now supportive, immigrant patient supports expanded).
• Family stories demonstrate trust-building: teens opened up about depression, families disclosed housing insecurity, parents recognized their own mental health needs.
• Quantitative outcomes include higher well-child attendance, more psychosocial assessments, greater anticipatory guidance, and better developmental/behavioral follow-up.
• System outcomes include improved provider morale, lower turnover, and community voice being elevated in decision-making

Measurement for Success

Success is tracked through both qualitative and quantitative methods:

• Family and provider satisfaction surveys
• Tools include:

  • Family Engagement in Systems Assessment Tool (FESAT)

  • Institute for Patient and Family Centered Care assessments (IPFCC)

  • Generate and Teach Health Equity Routinely (GATHER)

  • Promoting First Relationships (PFR)

  • First Approach Skills Training for Early Childhood (FAST-E)

• Metrics include:
  • Percentage of underserved families receiving CHW support
  • CHW participation in team-based care huddles
  • Decreases in ER visits and no-shows
  • Positive trends in perinatal mood disorder screening outcomes

Payment & Funding

• Funding type: Combination/braided funding
• Anticipated gains: Team-based CHW care produces financial savings (reduced ER visits, staff turnover) and human returns (improved parental mental health, flourishing families, stronger community stability). The model demonstrates that the “right care at the right time, in real time” yields many benefits across systems.
  
  • Teams enable whole family care and connection, i.e, CHWs frequently assist parents in connecting to mental health resources social health needs, and concrete needs
  • CHWs connect with families from the start, thus families know where to turn, spend less time seeking resources, feel they matter, experiences a decrease in frustration and futile actions, and build trustworthiness in a system not always worthy of trust
  • Ability to employ prevention, promotion, and treatment efforts effectively, even before diagnosis (not waiting until crises arise and untreated concerns cascade)

Resources

• Issue Brief: A Pathway for Sustaining Community Health Workers In Pediatric Primary Care in Washington 
• Early Childhood Family Needs Screening 
• First Approach Skills Training (FAST) 

To learn more about this innovation please email Rachel Lettieri, Director of Care Transformation at Pediatrics Northwest: [email protected].