Addressing social determinants of health, such as socioeconomic status, employment and housing, is crucial for improving health outcomes of young children. These challenges have been compounded for many families during the pandemic. Lost income had furthered food and housing insecurity, with 14 percent of families in households with children reporting that they or their children sometimes don’t have enough to eat.

Routine pediatric care has also been disrupted. A recent survey found 25 percent of households have a child who has missed a preventive appointment in the past year, while the rate of routine vaccinations has sharply declined during the pandemic. Additionally, young children are experiencing profound stress and uncertainty during a crucial stage of development.

The American Academy of Pediatrics found that the duration of the COVID-19 crisis, the need for quarantine and physical isolation and uncertainty about the future have eroded emotional and behavioral well-being. “Populations with a higher baseline risk, such as populations of color, communities and families living in poverty, historically under resourced communities, children who are refugees and seeking asylum, children and youth with special health care needs, and children involved with the child welfare and juvenile justice systems, may be especially vulnerable to these effects.”

“Health disparities cause a vicious cycle, and that has gotten worse during the pandemic,” says Boston Medical Center Community Wellness Advocate Lupita Estela. “It’s hard to focus on your child’s development if basic needs like food and housing aren’t being met. It’s so important that we’re there to help families meet basic needs so they can free up some of that mental and emotional space so they can really care for their child.”

To that end, the Center for the Urban Child and Healthy Family and BMC’s pediatric primary care team are working with families to understand and support their unique needs throughout COVID-19 and beyond. This initiative is part of the Center’s Pediatric Practice of the Future, first developed in 2019. The initial goal was to create a new model of care that involved families in the co-creation of the program.

“First and foremost, what we learned was that families want support around their economic well-being,” says BMC Center for the Urban Child and Healthy Family Program Director Carey Howard. “Particularly during the pandemic, we’ve really seen these areas of need for families come to a head, and a place like BMC is where families are often looking for wraparound support.”

The Center takes a novel approach to delivering pediatric care. This starts with an enhanced care team that includes the pediatrician and the community wellness advocate, along with a dedicated financial counselor, nurse, social worker and scheduler, who meet weekly to coordinate families’ medical and psychosocial needs.

At the center of the team, in the driver’s seat, is the family. Team members meet with families over time to gain a deep understanding of their long-term goals and aspirations for their child’s care. Together, families and team members work together to tailor their child’s primary care to address specific parents’ wishes and desires. This responsiveness and co-creation aims to transform families’ experiences and expectations of how health care works.

The Center’s community wellness advocates serve as an important and supportive longitudinal relationship—such as conducting pre-visit planning ahead of well-child visits, assessing needs and priorities and connecting families with the team’s financial counselor—in an effort to help families thrive.

Redefining primary care

Many of the supports the Center offers are outside of what would be considered traditional primary care, yet they are inextricably linked to children’s health and well-being. Financial counseling is core to the program. Throughout the pandemic, many families have experienced losses in employment, child care and other family resources. The fact that the financial counselor is already an established member of the family’s care team has smoothed the process of supporting families in dealing with these losses.

“Whether they’re facing a housing crisis or lack of childcare, that has been compounded by COVID-19,” says Howard. “These problems are quite pervasive, and they trickle down to children. Really listening to families and helping them navigate the complexities of health care, housing and education systems adds a layer of support they might not otherwise have.”

Through approaches like family asset mapping and goal setting, the community wellness advocate is well-positioned to identify and support families’ needs and priorities for their care in a responsive and holistic way. For example, during pediatric clinic visits, linking parents to their own primary care and connecting parents to financial planners are top priorities, along with administering vaccines and tracking each child’s growth.

The care team helps families with everything from physical and emotional well-being to family planning to financial needs, all tailored to the families’ stated goals and priorities.

“When we asked families what health means to them, they first said absence of illness and secondarily, many said spiritual well-being,” says Howard. “That was profound for us—a moment to recognize that families are thinking beyond medicine. We realized that spiritual support was an aspect of the hospital that we might not have been using to its full potential as a way to help families during difficult times.”

Emotional support is also key element of the program.

“COVID-19 has stretched mental health supports to their absolute capacity,” Howard says. “That’s why having integrated behavioral health embedded in our pediatric care is crucial. We’re shifting the dynamic, so families see social workers as a source of strength.”

Community wellness advocates are the face of the program, regularly talking with families to tackle different areas of concern and partnering with them to achieve their goals. “Even though needs may be amplified during the pandemic, it’s rewarding to see that we can help families build a toolbox of skills to resolve issues as they come up,” Estela explains. “It starts to feel more manageable for them.”

This was the case with a family Estela is working with through the program. Facing mounting debt, the family’s primary caregiver had a great deal of anxiety around childcare and housing. At one point she worried that their utilities would be shut off. Estela built a relationship with the family to help them tackle issues before they became a crisis. Over time, the conversations changed. “We’ve gotten to know each other well, and now when we talk, she’s more relaxed,” says Estela. “She knows if anything comes up she can reach out to us.”

This example demonstrates how supporting families more holistically can have a profound impact on children. As parents contend with ongoing challenges amid the pandemic, they can rely on this multidisciplinary center to build a safe and nurturing environment. “Although the challenges are greater during the pandemic, our work to set families up for success remains the same,” concludes Estela.

As of summer 2021, 100 families across the Boston area participated in the pilot program.