Flourishing in Action: A Texas Health Center’s Approach to Transforming Care by Engaging Families and Promoting Early Relational Health
Family connection is at the heart of pediatric care. Supporting the early relationships between children and their caregivers is foundational to lifelong health, well-being, and flourishing. Fostering early relational health and engaging families as partners in care are critical to setting children on a path toward healthy development and can ultimately drive larger systems change.
In this piece, Louis Appel, MD, MPH, Director of Pediatrics at People’s Community Clinic in Austin, Texas, and Christina Bethell, PhD, MBA, MPH, Director of the Child and Adolescent Health Measurement Initiative, Johns Hopkins University, highlight the importance of advancing flourishing through intentional focus on early relational health and family engagement in well-child care. Drawing from their experiences in clinical care and systems-level research, Drs. Appel and Bethell share tools, frameworks, and strategies that can help health care providers, community health center staff, and early childhood professionals create stronger connections with families and ensure every child has the opportunity to thrive.
A Shared Vision: Advancing Flourishing to Support Lifelong Health and Well-Being
As a pediatrician (Dr. Appel) and a child health systems improvement researcher (Dr. Bethell), our shared north star is supporting families and communities in fostering the early and lifelong flourishing of children. Pediatrics is uniquely positioned to support parents and caregivers in setting infants and young children on a trajectory toward lifetime health and well-being. The growing understanding of the impact of early childhood experiences, both positive and adverse, has brought pediatrics to what the American Academy of Pediatrics calls the “cusp of a paradigm shift” where the promotion of relational health – “the capacity to develop and maintain safe, stable, nurturing relationships (SSNRs)…”– is prioritized and recognized as critical to flourishing across the lifespan (Garner and Yogman, 2021).
Flourishing is a concept that recognizes that the absence of illness or risks is not the same as the presence of well-being and positive experiences. National measures of early childhood flourishing assess positive health characteristics essential for healthy development, such as positive attachment to parents/caregivers; resilience; engagement in learning; and emotional openness, empathy and communication. Child flourishing strongly predicts school readiness (Figure 1), social success, and mental health. Importantly, population-based studies confirm that family resilience, caregiver-child connection, and positive childhood experiences promote child flourishing and school readiness, even among children who experience adversities like adverse childhood experiences (ACEs), poverty, or chronic conditions (Bethell et al., 2019).
Figure 1. School Readiness for All U.S. Children Age 3-5 Years by Child Flourishing Index Score (Count of Items With a “Usually/Always” Response)
For infants and young children, the pediatric well-child visit is among our greatest opportunities to promote children’s healthy development and flourishing and prevent future chronic physical and mental health problems. We can engage families before children enter school through leveraging the 15 well-child visits that are recommended to occur in the first critical months and early years of a child’s life for relationship building and early support of caregivers. By turning our knowledge about the importance of early relational health into action, we can help ensure every child can flourish. Doing so is already aligned with the national Bright Futures Guidelines, which map out priority health education topics and the whole child and family screenings important to promoting healthy development.
How the People’s Community Clinic in Texas Integrates Early Relational Health into Routine Well-Child Care
For over a decade at Dr. Appel’s People’s Community Clinic (PCC) in Austin, Texas, the clinic has focused on promoting flourishing by making early relational health – and its central role in optimizing early brain development – the organizing principle of its well-child care for young children. PCC’s approach to care aims to support parents/caregivers in promoting early brain development and relational health through education, skill-building, staff training, redesigned well-child visits, and connecting families to resources that reduce underlying sources of stress and address non-medical drivers of health.
PCC integrates existing programs, resources, and frameworks with its own approaches to incorporate early relational health promotion and family engagement into care. They have used frameworks like Harvard’s serve-and-return model and Stanford’s Filming Interactions to Nurture Development program to provide universal messaging, behavioral and developmental supports, and comprehensive interventions to families. Staff have participated in the University of Washington Barnard Center’s Promoting First Relationships in Pediatrics trainings, as well as training in tools like the Welch Emotional Connection Screen and for incorporating early relational health promotion into the Reach Out and Read program. PCC has also worked to restructure the well-child visit itself through implementation of the HealthySteps program, videos for anticipatory guidance, and help from community health workers to give providers more space to focus on relational health during visits.
Overcoming Challenges in Screening and Relationship Building
Even with these efforts, there were still challenges in efficiently conducting child and family screening, proactively engaging families to learn about and identify their own goals for well child visits, and obtaining the child, family, and whole population data needed to understand needs, outcomes, and quality of care. A large portion of PCC clinical team time that could be dedicated to building relationships with, educating, and supporting families was going to trying to conduct basic assessments on child development or family health and social needs screenings.
To address ongoing challenges and transform care further, in late 2023, PCC began to employ the family-facing, Bright Futures Guidelines-aligned Well Visit Planner (WVP) digital health tool, developed through Dr. Bethell’s research and team as a part of the larger Cycle of Engagement Model (Figure 2). The WVP addressed many barriers while further engaging families as partners in care, ensuring their priorities are understood and all screenings are conducted in a way that educates and supports families, as well as pediatric clinical teams.
Figure 2. Illustration of the Cycle of Engagement Well Visit Planner Approach to Care and Tools
As an example, at a recent well-child check for a child with previously identified developmental concerns, a mother shared, through her responses on the WVP, both her excitement about a developmental milestone her child had achieved and information indicating her own social isolation. Dr. Appel was able to begin the visit with relationship-affirming shared joy in the child’s developmental progress, while also having the opportunity to engage in a conversation about the mother’s challenges with social supports. He learned that these challenges were creating a barrier to getting the child connected to early intervention services. With this information, Dr. Appel praised the mother for all she was doing and alerted clinic staff to provide the mother with additional support in making the connection to early intervention services for her child.
The WVP can also produce population-based data so PCC can begin to see child and family risks, strengths, and priorities across all the children and families they serve and better align supports to meet those needs and address priorities. Using the Well Visit Planner has helped PCC to free up time to focus on the critical work of promoting early relational health in partnership with families, who are also more engaged and receptive to discussions and support to promote relational health at home.
While PCC’s practice has been greatly enriched through specific programs and activities, the basics of incorporating early relational health into pediatric practice do not require special programs. Incorporating early relational health into practice is really about focusing on the reason many of us involved in the care of children entered the field in the first place: to establish trusting relationships with caregivers and children; to observe caregivers and children interacting and to listen and wonder with them about their concerns; and to provide strengths-based feedback to caregivers about the positive things they are already doing, encourage and commend them, and help them see how those interactions support their children’s development and health. It is also about recognizing that the trusting relationship we have with parents/caregivers—authentically listening to concerns, reflecting, offering positive reinforcement—is itself therapeutic even in situations where we have no outside resources to offer. This focus on early relational health and family engagement is not only beneficial for families but also can help reduce burn-out for health care providers and staff.
Partnering for Widespread Change and Refocusing Care to Promote Flourishing for All Children
While individuals and practices like PCC can do much to promote flourishing, to create the type of change we ultimately want to see in our communities, broader community-wide efforts are needed for widespread transformation. Recognizing this need, Dr. Bethell facilitated the design of the Engagement in Action Framework (EnAct!), which sets forth a “through any door” approach to engaging families using tools like the Well Visit Planner and highlights that effective pediatric care requires collaboration across health care, public health, schools, and other community-based supports (Figure 3). EnAct! is anchored to the science of flourishing and the importance of promoting positive childhood experiences and child and family resilience.
Figure 3. Illustration of the Engagement in Action Framework’s Through Any Door Approach
The framework lays out steps to achieving a system where community- and health-care-based access points seamlessly link families to support via a family-driven platform for determining needs and priorities and where leadership is shared among families, community organizations, and health care providers to drive meaningful, coordinated support. Families in particular are central to EnAct! as they must be engaged at all levels of system change efforts and empowered to share their valuable perspectives and experiences to ensure the systems created are based on supporting them and their needs.
Amidst the electronic health record clicks and the pre-authorizations, it is important to remember that the thing pediatric health care workers probably cherish the most in the workday—that moment of connection with a family—is not the part of the care to be weeded out for efficiency’s sake, but, rather, is the core of our work that must be supported and protected for ourselves and the families we serve.
With the various tools and approaches that are available, ultimately, focusing on early relational health and family engagement brings us back to the basics of pediatric care. Amidst the electronic health record clicks and the pre-authorizations, it is important to remember that the thing pediatric health care workers probably cherish the most in the workday—that moment of connection with a family—is not the part of the care to be weeded out for efficiency’s sake, but, rather, is the core of our work that must be supported and protected for ourselves and the families we serve. It is valuing the power of the human connection we have with children and families; it is fostering the nurturing connection that caregivers have with their children; and it is advocating for policies that create an environment that supports families in having safe, stable, and nurturing relationships. And all of that is work we can engage in today.
About the Authors
Louis Appel, MD, MPH, Director of Pediatrics, People’s Community Clinic
Louis Appel, MD, MPH, serves as director of pediatrics at People’s Community Clinic in Austin, Texas. Dr. Appel provides primary pediatric care at the clinic in addition to overseeing the pediatric clinical programs. At the clinic, he has championed the promotion of early relational health and projects on group pediatric well-child checks, postpartum depression screening, lactation support, and childhood obesity prevention focused on the prenatal and immediate postpartum periods. He is a member of the Harvard Center on the Developing Child’s Pediatric Innovation Initiative working to develop a panel of biomarkers of chronic stress activation in children. He is a past president of the Texas Pediatric Society and also previously served as the Community Access to Child Health (CATCH) program facilitator for District VII of the American Academy of Pediatrics. A graduate of Princeton University, Dr. Appel received his medical degree from Harvard Medical School and obtained his MPH at the Harvard School of Public Health, with a concentration in public management and community health. He completed his pediatric residency at the University of Washington in Seattle.
Christina Bethell, PhD, MBA, MPH, Director, Child and Adolescent Health Measurement Initiative (CAHMI)
Christina Bethell, PhD, MBA, MPH, is a professor at the Johns Hopkins Bloomberg School of Public Health and School of Medicine. Her research focuses on building and translating the science of healthy development of children, youth, families, and communities. With roots in national and state health care policy, financing reform, and delivery system redesign, Dr. Bethell is the founding director of CAHMI which, since 1996, has worked to promote the early and lifelong health of children, youth, and families through family-centered data, tools, and research. She has developed and advanced an array of child and family health measures to address the social and relational roots of well-being and the quality of health care systems and structures that influence well-being, including nationally and internationally used measures of the family-centered medical home, adverse childhood experiences (ACEs), positive childhood experiences, family resilience, child flourishing, and the Whole Child Risk Index. Her research has led to the development of the national Prioritizing Possibilities agenda to prevent and address ACEs, providing testimony to the U.S. House Committee on Oversight and Reform on identifying, preventing, and treating childhood trauma, informing the American Academy of Pediatrics relational health policy statement and the design of the Engagement In Action (EnAct!) Framework to catalyze statewide integrated relational systems of care. She earned an MBA and an MPH from the University of California, Berkeley and a PhD in public policy and health services research and policy from the University of Chicago.
References
Bethell, C. D., Gombojav, N., & Whitaker, R. C. (2019). Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity. Health affairs (Project Hope), 38(5), 729–737. https://doi.org/10.1377/hlthaff.2018.05425
Center for the Study of Social Policy (2022). How to Communicate Effectively About Early Relational Health: What It Is and Why It Matters A Messaging Guide. Retrieved from https://cssp.org/
Garner, A., Yogman, M., & Committee On Psychosocial Aspects Of Child And Family Health, Section On Developmental And Behavioral Pediatrics, Council On Early Childhood (2021). Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health. Pediatrics, 148(2), e2021052582. https://doi.org/10.1542/peds.2021-052582
Bethell, C, Buttross, S, Leiser, D, et al. The Engagement In Action Framework (EnAct!) for a Statewide Integrated Early Childhood Health System. Accessed at: https://www.cahmi.org/our-work-in-action/engagement-in-action/EnAct!Framework
