When the Pediatrician Isn’t Enough

In Los Angeles County, the average family that uses the Northeast Valley Health Corporation for primary medical care is young and Latino. Many of the fathers work in the gardening business, and many of the mothers work in the restaurant industry. Most are immigrants, or first generation in California. They all want the best for their children.

Many of these families also struggle with housing, food insecurity, employment, and immigration. And while all of those issues directly affect the health of their kids, they aren’t topics that often come up in a general doctor’s visit.

“These are all things we could potentially give them resources for, but we haven’t done that consistently,” says Dr. Christine Park, the pediatric medical director for NEVHC. “In the course of a visit, you just don’t have time.”

A trial program set to begin at NEVHC and nine other clinics next year aims to change that. By augmenting the work of oversubscribed doctors like Park with trained health educators, the PARENT program (short for Parent-focused Redesign for Encounters, Newborns to Toddlers) is designed to foster a more holistic approach to children’s health care in the communities that need it most.

Conceived by Dr. Tumaini Coker, a pediatrician at Seattle Children’s Research Institute Center for Child Health, Behavior and Development, and funded by a $3.2 million grant from the National Institutes of Health, the five-year PARENT program trial is the latest of several similar initiatives aimed at improving prevention-oriented care. The program adds a “parent coach” to the pediatric team to handle the social and behavioral questions that a doctor is supposed to address in visits, but often doesn’t have the time to tackle in depth.

The American Academy of Pediatrics provides physicians with guidelines for each patient appointment requiring a full complement of measurements, tests, questions, and screenings at each stage — even before addressing parent’s specific concerns. This leaves little time for discussions of important but ancillary health issues that often disproportionately affect low-income communities, from mental health and behavior issues to food insecurity, community violence, and other social contributors to overall health.

Dr. Yovana Bruno runs one of two clinics that participated in the pilot run of the PARENT program in 2014. Over the course of a year, when families arrived at her office in Duarte, California, they filled out a form highlighting social, developmental or behavioral concerns. Then — before meeting with Bruno — they sat down with a health coach. “They talk about nutrition, hygiene, and try to get more detail about the social situation,” Bruno says. “They talk about common disease, when it was important to go to [the emergency room], and when it’s not important.”

The time spent with the health coach helped to ease the burden on the Bruno to cover everything at once — and the program’s initial results are encouraging: Parents reported better screening for family risk, better health education, and more robust developmental screening. There was also a drop-off in emergency room trips, with only 10 percent of the children in the program making two or more ER visits, compared with 20 percent of the children who weren’t in the program.

Of course, pediatricians have been struggling for years to find ways to improve primary care. One of the most established and well-studied programs to do this is called Healthy Steps, which is now housed at the Washington D.C.-based non-profit Zero to Three. Used in almost 100 pediatric practices nationwide, Healthy Steps shares features with Coker’s PARENT model, but is more comprehensive. Healthy Steps not only places an additional team member in each practice to discuss social and developmental issues, but also includes home visits, extensive mental health screenings for parents, and other services.

Parents enrolled in Healthy Steps report increased satisfaction with care, were more likely to stick to appointment and vaccination schedules, and were better able to identify concerning behaviors in their child.

Jennifer Bronsdon, a child development specialist in the Healthy Steps program at Massachusetts General Hospital, remembers a particular patient: an 18-month-old boy.

“I was starting to notice some language delays, and I helped connect the boy with early intervention services,” she says. “I actually called a special education advocacy agency, and was able to get an advocate for the family…These are things that the doctors don’t have time to do.”

For parents, these sorts of interventions can seem invaluable, but they often don’t translate into a direct financial benefit for the doctors implementing them, raising questions about their sustainability. The PARENT program, for example, requires paying the salary of an additional professional — which Coker’s study estimates to be around $10,200 per physician, per year. This is something that Medicaid doesn’t cover. And while Bruno’s patients made fewer visits to the emergency room — saving money for the health care system overall — she didn’t see those extra dollars come back to her practice. Without an independent grant or other form of outside funding, doctors like Bruno simply can’t recoup their costs.

At Healthy Steps, the policy and finance team works with physicians to find ways to get extra services reimbursed by identifying Medicaid billing codes that apply to some of the services provided. The team has identified six potential avenues for reimbursement that they’re hoping to roll out in the near future, says Jennifer Tracey, director of policy and finance for Healthy Steps. She thinks those will remain viable, even under changes that may occur under the new presidential administration of Donald J. Trump.

“We work with a lot of wonderful policy wonks in the DC area,” Tracey says. “We’re always facing an uphill battle educating policy makers on importance of early child intervention, regardless of administration.”

The Northeast Valley Health Corporation has had some success funding other experimental programs after initial grants ended, including keeping a pediatric asthma and a gestational diabetes program running. Park says their goal is to do the same with the parent coach model after the PARENT trial ends. “The hope,” she says, “is that we could sustain it on our own.”

Whether they will succeed remains unclear. Funding for the PARENT trials at Bruno’s clinic and at Wee Care Associates in Compton, has already dried up. After seeing the success of the program at her facility, Bruno worked to find ways to keep some semblance of the program in place. She managed to scrape together the money necessary to keep a health coach on staff for a few hours a week after the study ended in January 2015. But her part-time educator recently had to leave, so Bruno is applying for grants and looking for someone new.

“I just hope that I can get someone to help us soon,” she says.

Nicole Wetsman is a health and science writer based in New York. Her work has been featured at New Scientist, STAT, Science Friday and others. Find her tweeting @NicoleWetsman, mostly about brains and women’s soccer.