Background

The benefits of home visitation services for families at risk with children from zero to 3 years of age are well documented (Duffee et al., 2017; Olds et al., 2010). Children’s development and health outcomes as well as school readiness are improved. These benefits to children and families are also known to produce cost savings to society (Olds et al., 2019). Simultaneously during the early years, children participate in pediatric well care with greater visit frequency from birth through 3 years of age. Pediatric anticipatory guidance provision complements the health assessments, immunizations, and parental support at these visits. Most pediatric facilities base their well-child services on the American Academy of Pediatric Bright Futures guideline that are evidence-based whenever possible (Hagan et al., 2017). Yet, as more recommendations are rolled into Bright Futures each year, there are calls for reorganizing the way care provision occurs in an evidence-based manner. One promising strategy identified is the use of non-medical personnel in the provision of advice around child development (Coker et al., 2013; Kuo et al., 2006). There is often overlap between pediatric and home visitation services, with some redundancy and perhaps some omissions in the provision of basic care. There may be great potential in creating synergy when both systems work together. Home visitors would be logical partners in pediatric care redesign.

Over the past 25 years, a growing number of pediatric offices and home visitation entities have begun exploring such options of co-location of services or service integration. One such example, funded by federal dollars, is underneath the guidance of South Carolina Children’s Trust. Eleven home visitors have been embedded in pediatric clinics during the past 5 years across South Carolina. In another example, in Springfield Missouri, local pediatric offices have partnered with Parents-as-Teachers home visitors to supplement and support their anticipatory guidance (Parents as Teachers, 2021). There are other nascent partnerships elsewhere. But these efforts have insufficient clarity and consistency in their goals and objectives upon which to determine impact and compare them with efforts elsewhere. Without clear goals and evidence for linkages between these medical-home-visiting collaborations, it is difficult to approach funders and policy makers for support, or even be able to evaluate if any sustainable benefit exists. We propose suggested additional avenues upon which to build a more robust evaluation of the net gains and challenges of home visitation pediatric partnerships.

Concerns

Several questions therefore arise—What are the redundancies if any and how do they affect service delivery efficiency? How can the primary pediatric team and the home visitation team work together to maximize outcomes, to maximize efficiencies, and to document their efficacy to justify their continued, and hopefully enhanced, funding? Is there an opportunity for a synergistic impact greater than that the sum of both home-visiting and pediatric services if both work together (Rushton & Kraft, 2014)?

There is a current evidence base for embedded home visitors in pediatric settings, but it is scanty. Evaluation of Healthy Steps, a Boston originated effort replicated across the country, has shown some solid gains in health and development by adding a “developmental specialist” into the pediatric office (Minkovitz et al., 2003, 2007). The developmental specialist has more time with the family in the pediatric clinic than the clinicians and is thus able to provide greater focus on a variety of anticipatory guidance topics. These developmental specialists do home visits and assessments, but most of their services are provided in the pediatric medical home. As a result, some consider it not to be a home-based service and it does not qualify for federal home-visiting dollars through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program.Footnote 1 Though Healthy Steps is not a pure home visitation, its positive efficacy lends support to the notion of a home-visiting professional assisting in pediatric clinical services.

Another small study documented efficacy in a Parents-As-Teachers (PAT) and pediatric medical home partnership (Well Baby Plus) in which services were provided jointly. Well-child visits were provided in a group format and all families were enrolled in Parents-as-Teachers. Participants were noted to have better retention of anticipatory guidance information, higher completion rates of well-child visits, improved satisfaction with care, and less early onset obesity than their peers receiving pediatric care in a traditional setting (Rushton et al., 2015).

A substantive random controlled trial of home visiting come from the Better Health Care (BHC) in Rochester (NY). Intervention families were enrolled in a tiered model of PAT home visitation linked to the medical home. Home visitors in addition to parenting education with the PAT curriculum were able to focus on family mental health and psychosocial issues. BHC was able to report avoidance of child protective services, improvement in well-child visit completion rates, and increased referrals for mental health services among other gains (Paradis et al., 2013).

Professional Support

In spite of the limited evidence, pediatric voices have been calling for expanded partnerships between their services and home visitors. A quarter of a century ago in 1996 published calls were made for the creation of synergistic partnerships with home visitors and pediatric offices as a strategy for child abuse prevention in South Carolina (Rushton, 1996). In 2009, the American Academy of Pediatrics’ (AAP) Council on Community Pediatrics suggested linkages between home visitation programs and pediatric medical homes, stating that:

Little research has been performed on the linkage of home visitors to pediatric medical homes, which is an area that deserves attention. There is ample reason to believe that the synergy of home visitors working with pediatric clinicians could have positive effects on child health and development. Home visitors should be considered to be a complementary collaborative partner in the provision of developmental assessment and other components of well-child services.

A 2013 Academic Pediatric Association/American Academy of Pediatrics Joint Workgroup on the Family Centered Medical Home called for integration of early developmental and pediatric services. Potential benefits were suggested, such as improvements in care communication and management and an ability to become more family focused, although there was little data upon which to make these recommendations (Toomey & Cheng, 2013). By its very name, Nurse Family Partnership (NFP) is a medical partnership, although usually not with pediatric offices (McConnell et al., 2020). Parent as Teachers (PAT) in their exploration of working with pediatric offices in Springfield, MO, is self-publishing a consensus paper on such partnerships (Parents as Teachers, 2021).

Value

In early 2020, a working group meeting in was held Charleston, SC, under the auspices of the South Carolina Chapter of the American Academy of Pediatrics. Attendees were clinicians and their staffs who have worked in offices with home-visiting services from South Carolina and Missouri.Footnote 2 The intent was to develop a broad list of perceived outcomes and aims for home visitors embedded in pediatric offices that could be subjected to further study and validation. This list was to include measurable items useful in continuous quality improvement or in future research to document efficacy. The working group’s perceived value items fell into broad categories (Table 1).

  1. 1.

    Joint monitoring of patients and clients. Ideally, there should be improved communication and care coordination among care providers. When referred for home visitation services by the pediatrician, we would anticipate higher rates of engagement of families by home visitation programs. Children and families will be more likely to have been screened for physical conditions, development, behavioral and mental health issues, socio-environmental factors including those related to toxic stress, pervasive development disorder, language development, literacy promotion, and parental concerns (Burrell et al., 2018). Reports from the Netherlands (Staal et al., 2015) indicate that screening for parenting and developmental problems is more effective when done in the home rather than the well-baby clinic.

  2. 2.

    Enhanced attention to mental health and social-environmental issues: Many suggest that home visitors and pediatric staff working together will have additional opportunity to identify and refer to other services in the community. Maternal depression and other holistic issues will be more likely to be addressed and there will be better opportunities to reduce toxic stress and its impact on brain development.

  3. 3.

    Enhanced relationships and trust with and within families: Continually evolving relationships between home visitors, client-patients, and pediatric medical homes are powerful and therapeutic. Improvements in relationships between all parties should result in increased satisfaction for families, patients, home visitors, and medical homes. In a Winston-Salem (NC) medical home-visiting partnership, gains were noted in engaging fathers, support of parents, and increased time for parenting education (Linton et al., 2018). As relationships improve, trust in service providers grow improving family/patient compliance (Sisk & Jacob, 2019).

  4. 4.

    Better health care utilization: Although other studies have not been consistent, decreased numbers of emergency room visits, hospitalizations, and other positive impacts on other utilization of medical home services should likely ensue (Anugu et al., 2017; Davis et al., 2018; Goyal et al., 2020). Parental convenience (especially with shared home visitation visits) should improve. Others have already found that home visitors could improve well-child visit completion rates (Goyal et al., 2016). Potential gains would include diminishing redundancy, improving immunizations, better delivery of American Academy of Pediatrics’ Bright Futures or other well-child content, better family anticipatory guidance retention as opportunities arise to reinforce parent messaging, improved family health literacy, better adherence to recommendations and follow-up, greater acceptance of, and enrollment in home visitation services (Ammerman, 2016; Guastaferro et al., 2020). Programmatic issues such as formal partnership agreements, consent agreements, and service integration agreements can be measured as steps toward achieving these goals.

  5. 5.

    Significant improvements in child and family outcomes: We anticipate diminished child abuse and neglect. Significant work has been done to demonstrate home-visiting programs as effective in preventing child abuse and neglect, but it is possible that a strong relationship with the medical home will strengthen its impact (Goyal et al., 2013). We would expect to see a positive impact on infant and toddler development, including an impact on school readiness. Improvements in well-child-care utilization should result in improved nutrition, less obesity, a decrease in accidental trauma, and preventable diseases. We should see improved social emotional competencies and literacy upon entry to kindergarten. We would anticipate improvements in parent sense of competence and efficacy and improvements in family mental health. These efforts would enable conditions to support ultimately health equity (Barboza et al., 2018).

Table 1 Perceived value for primary pediatric-home visitation partnerships
Full size table

There are a lot of reasons to anticipate stronger families and healthier children with collaboration between pediatric practitioners and home visiting. But the data supporting these recommendations still needs substantial additional development.

Barriers to Collaboration

Those promoting home-visiting pediatric collaboration also need to understand the barriers to collaboration. The work group in South Carolina developed a list of barriers to home-visiting pediatric medical home partnerships (Table 2).

  1. 1.

    Lack of a robust evidence-base: As previously mentioned, the lack of a robust evidence-base interferes with both funding opportunities and provider-patient acceptance.

  2. 2.

    Complex funding issues. In the USA, pediatric offices still tend to operate on a fee for service basis and home visitors are often funded through grants.

  3. 3.

    Lack of understanding: Despite calls from their professional organizations, there is a lack of understanding of home visiting by pediatric providers and often a corresponding ignorance of pediatric well-child-care by home visitors. These factors lead to limited appreciation of value each partner brings to the process and a lack of buy-in. Pediatric office personnel are often confused by the array of different programs and their features, including whether home visiting should be universal or targeted (Finello et al., 2016).

  4. 4.

    Inertia: Resistance to change in the way care is provided is hard to overcome. Well-child pediatrics is becoming more team-based over time, but inertia is an issue. Some areas of the USA have had modest success with using quality improvement techniques to overcome this inertia.

  5. 5.

    Family acceptance: Acceptance of home-visiting services is often an issue. Identifying those families most likely to benefit is sporadic, and even when offered, many families are reluctant to accept care because of a perceived stigma.

  6. 6.

    Workforce issues. There is a perception of a lack of skilled workforce for home visiting that often correlates with access problems with child health care.

Table 2 Barriers to primary pediatric medical homes/home visitation partnerships
Full size table

There has been a steady growth in the number of pilots for children’s clinic-imbedded home visitation programs. There are recommendations from the major pediatric professional organizations to pursue integration and co-location of medical services with home visitation. There is a slow but consistent growth in home visitation dollars through state contributions and the federal MIECHV program with bipartisan support. There is a scant but growing evidence base for these partnerships. But there is a lot of questions still about the impact of these collaborations and insufficient data to support their expansion.

Program aims should be tailored to the context of national systems, community, and the nature of local partnerships. Specific aim statements can guide programmatic guidance at the local level and confidence in the value of the services being provided. Specific aims also lead research, comparing families who receive no services, or individual pediatric well-care, isolated home visitation services or care provided in a service integrated fashion. Only then can we advocate for expanded linked services, collaborative services that many think could have a meaningful impact on child health care and development (Condon, 2019).