Redesigning the pediatric practice for whole family care
Boston Medical Center is New England's largest safety net hospital, serving the region's vulnerable communities and patients. The Center for the Urban Child and Healthy Family is focused on revolutionizing the model of care for pediatric patients and their families.
We partnered with this team to take a family-centered approach to the creation of a new model of care. The Pediatric Practice of the Future, launched into pilot January 2020 and now serving 100 families, was co-designed with families, staff and providers. The practice centers pediatrics as a hub for care and resources for families of young kids, leveraging the frequency of visits during a child's early years. It focuses on families' and children's social determinants of health to ensure that kids are healthy and ready to learn when they enter school at age five.
The practice is focused on whole family care, emphasizing wellness of the family unit during these years. The core tenets of the practice stem from interviews and co-design work with parents.
Shared expertise: Providers and families both bring expertise to the relationship. Parents emphasized that they understand their children, contexts and goals in ways that are important to their provider being able to care for their family well. The experience of the practice centers the expertise of the family and creates tools and interactions that surface this insight.
Planning skills: While all of the families we worked with during the design process had clear goals for themselves (for example, moving out of a shared apartment or successfully breastfeeding), not all were meeting these goals. Those who were, had clear plans, a sense of their own assets and capacity to complete these plans, knowledge of what resources they needed -- and a backup plan for when things went wrong. By organizing care around families stated goals, the practice supports families in doing this type of planning, with their child's health as an entry point.
Community engaged: Families talked about health as more than just physical. Caregivers described how their children's health related to their spirituality, their mental and emotional well-being, their environments and support systems. The practice works with families to map their ecosystem, framing the context of care within the families broader universe of relationships, services, assets and potential needs.
Common agenda: Parents are problem-solvers, and the moms that we spent time with described the many ways they identify issues and find resolution. The doctor's visit needed to be another tool for them in this process. The practice now engages caregivers before each visit to set the agenda for the appointment and ensure that their time with their provider is organized around their priorities.
The project team from BMC included a mix of administrators, frontline pediatric staff, providers (practicing pediatricians) and researchers. We partnered with this team through the following stages of work.
We spent time with parents and kids in their homes. From taking time out of an interview for a two-week old's feeding to drawing pictures with a two-year-old, these sessions were relaxed and intimate.
Our team has shaped our interview approaches using trauma-informed approaches, seeking to make our interactions trustworthy, transparent, and empowering to respondents and not to pathologize what we learn about their experiences and contexts. During these interviews, we learned about traumatic aspects of these people's lives, such as domestic violence, fears about immigration status, and life in post-hurricane Haiti, as well as their impactful healthcare experiences, including miscarriage, mental illness, and chronic disease. Creating a safe, validating interview space that does not judge these women or their experiences helps our team ensure that we don't retraumatize people when asking them to share about private aspects of their lives.
Our interviews were structured to understand participants' lives and contexts, not only their experiences as patients. Framing their broader ecosystem was critical to identifying opportunities for this new pediatric practice to partner with parents on social determinants of health. We sought to understand how caregivers framed their role as parents, how they thought of "thriving" for their family, and how their "village" of support systems looked.
Finally, it's worth noting that we sought to use tools and activities that were inclusive and open to a range of cultural interpretations.
Understanding the current practice and staff
We spent time understanding the current practice operations and the perspectives of a range of staff. We observed a day-in-the-life of the practice, from morning opening to routine charting and visits.
Interviews with doctors, medical assistants, nurses, patient navigators, community health workers, social workers highlighted a range of perspectives on the needs of families and on the ways that the current practices served them.
Patient navigators, for example, discussed the challenges they faced in connecting the directions of providers with the expectations or desires of families. Their example of co-sleeping made this tension tangible. On the one hand, they said, a family may be sharing a bed because of cultural norms or a lack of space. On the other hand, the provider may direct them to send the family home with a Pack-and-Play. They spoke of the need to prioritize interventions for families with clusters of needs and to pace the work that they do together over time and across a developing relationship.
Community health workers shared examples of how they worked with children and families with particularly high need/high opportunity conditions. They shared the highly relational and intimate ways that they partnered with families to understand their child's disease, how to manage it, and how to do so in the context of their lives. One team member shared how she talked about asthma, drawing for us the way that she shows families how the lungs work, using a metaphor of tree branches and leaves to explain bronchioles and air sacs. She said that understanding how asthma affects their children was a critical first step in understanding how medications and their actions could help control it.
Insights about families
From this learning, a set of guiding themes and opportunities emerged. These grounded the ideation and design work and have continued to inform the BMC team as they iterate through pilot.
1. Opportunity: Create a common language around development to normalize and validate families
- Parenting is an N-of-one: Parenting can be a vacuum. Every parent is -- to some extent -- doing it on their own. They have limited points of reference with which to understand their (and their child's) experience.
- Parents work towards progress indicators: Goals and plans related to parenting and child development were driven by a set of progress indicators. Our parents understand their child's well-being and growth against a very limited and specific set of progress indicators.
2. Opportunity: Build planning skills in big ways and small
- Parents are problem-solvers: Parents are responsive. They're in a constant loop of problem spotting, solution identification, and acting on this solution.
- Goals vs. plans: All of our families have goals: whether for themselves, their family or their child. These can be proactive goals, like a degree to get a better job, or reactive goals, like a weight target for a new baby. Reaching goals feels great! Respondents beamed when they talked about goals reached.
3. Opportunity: Execute on this in ways that reflect family beliefs and values
- Parents think of health and wellness differently. Definitions of wellness and health varied significantly across families. While every parent focused on physical health and well-being, other parents built upon this to include additional aspects, including spiritual, mental, environmental and social.
- Family values: Parent values were surfaced through two themes that we heard about in nearly every interview: food and money. Through these two topics, we were able to understand what parents value (and often lack) in their lives and experiences: control, choice, tangible feedback and clarity.
We worked with families and staff during the ideation and solution-generating process. We facilitated a series of co-design sessions, during which teams worked together to brainstorm ways that these insights about families could be translated into a new practice experience.
Families included both those who were interviewed during the learning stage and members of the Center's existing Family Advisory Board. Childcare was provided; food was ordered; and brainstorming happened in the context of a meal, with kids floating in and out. These sessions helped to validate the insights, as caregivers affirmed the resonance of the themes. And much of the brainstorming focused on experiences from beyond healthcare that families valued. These were opportunities for the practice to work in ways that reflected how families' communities and services operated.
Co-design sessions with staff were demonstrations in power-sharing, with team members of different levels working alongside each other. The family-centered nature of the brainstorming process leveled the field a bit, so we saw medical assistants and other staff leaning into this shared expertise (around family needs and values). These sessions generated ideas around opportunities to scale up practices that were happening in pockets or past initiatives that had been mothballed, as well as ways to work in interconnected manners for families.
In January 2020, the Center for the Urban Child and Health Family launched the pilot of the Practice of the Future clinic, embedded within pediatrics primary care at BMC. An "innovation team," including a pediatrician, an infant mental health social worker, a community wellness advocate, financial coach and a nurse run a Wednesday afternoon clinic for families from the primary care practice. The innovation team strives to build an equitable health system that fosters families' self-efficacy and autonomy and promotes social and racial justice. As an aspect of this work, the Center partnered with the Boston Public Health Commission to conduct a tailored training curricula for our innovation, evaluation and project team on: Trauma Informed Care & Resilience; Racial Justice & Health Equity; and Stress & Vicarious Trauma.
Core elements within the Practice of the Future include a focus on economic well-being, family eco-mapping, family wellness plans and pre-visit planning. The importance of health care supporting economic well-being was lifted up by families during the design process as a fundamental way that health care could support them. The team is designing a menu of financial services, such as tax preparation and opening child savings accounts, which are systematically offered to families in the Practice of the Future pilot. Additionally, a recent grant enables a full-time financial coach within the team.
Family ecomapping is conducted by the social worker, and is a means to understand the greater environment in which the child and family are living (for example, social networks, community connections), the areas in which they are thriving and the areas in which they would like support. This process is used to inform a comprehensive family wellness plan that outlines families' goals for the next six months, including priorities for financial well-being. Finally, the community wellness advocate connects with families prior to their visits to ensure their time at BMC is organized around their priorities.
Core to the effectiveness of the Practice of the Future model is its ability to be scaled and sustained beyond the pilot program. As such, the Center is partnering to identify a payment model that supports the right "dose" of access to a variety of flexible health care services including behavioral health, community support and telemedicine, and to test new quality metrics that better relate to child and family well-being. Currently the Center is refining new quality metrics related to dyadic care, health equity, economic mobility and school readiness that could be administered within the clinical setting.