Much has been written about team-based care in the adult literature, but there is a paucity of information on what this should look like for children. A new AAP policy statement addresses how team-based care should incorporate what is unique about children and outlines what is optimally needed to support children and families.
The policy, Guiding Principles for Team-Based Pediatric Care, is available at https://doi.org/10.1542/peds.2017-1489 and will be published in the August issue of Pediatrics.
Team-based care for children is different from that for adults for three key reasons:
- Early environment and experiences have crucial effects on lifelong health.
- Resources targeted toward health promotion and disease prevention have significant societal benefits.
- Pediatrics fundamentally incorporates the dynamic nature of childhood.
Medical home ‘plus’
The policy recommends a team that continually works to keep children and their families or caregivers at the center. In addition, it’s important to think of the team as one that extends beyond and enhances the medical home, and is dynamic as the child grows/develops and is responsive to his or her changing needs.
For example, an infant’s team may include the pediatrician, a lactation consultant, the obstetrician-gynecologist if the parent is depressed and a community home-visiting program. A troubled teen’s team might include the pediatrician, foster parents, a child psychiatrist, a school psychologist and a wrap-around service provider.
While team-based statements produced by other entities do not specifically state that teams should be led by a physician, this policy clearly articulates that pediatricians are the ideal leaders of team-based care for children. The locus of leadership may shift over time, residing with the primary pediatric provider or the pediatric medical or surgical subspecialist, or it may be shared among them when appropriate. Also, the team’s composition and pediatrician leadership will change as the needs of the child and family change.
Does this mean the pediatrician must do everything? Absolutely not.
Pediatric lead
From an operational viewpoint, other members with child and/or adolescent expertise may be the most appropriate team leaders to oversee and provide details of care delivery. However, as the policy states, “A pediatrician (general pediatrician, pediatric medical subspecialist or pediatric surgical subspecialist) is uniquely qualified, on the basis of training and expertise, to oversee the team, provide administrative oversight and serve as a resource to promote optimal functioning while meeting the needs of the patient and family, given available resources.”
No single person or entity can meet the needs of a child and family throughout their growth and development. Team-based care asks us all to reflect on what we do best and identify opportunities where others can contribute, then work together toward a shared goal: to better meet the needs of children and families and help them achieve their potential.
Looking ahead
Much work is to be done if every child is given the opportunity to be served by a high-functioning team. These include the following, according to the policy:
- Payment models are needed to support appropriate payment for implementation, ongoing infrastructure, collaboration and continuous improvement to sustain team-based care for children and families.
- Medical school, residency training and continuing medical education need to incorporate principles and practice of team-based care and development of team leadership skills for pediatricians. Pediatricians will need education, implementation toolkits, technical assistance and infrastructure support to transform their practices.
- Implementation of technology-enabled communication is needed to establish, support and strengthen communication across the care team. Electronic platforms are needed to share medical records and key information in an accessible format so that all team members — including children and families — can communicate in real time, while respecting confidentiality.
- Children and families should be confident that they are at the center of the team. Shared decision-making skills are key to strengthening collaboration among team members, physicians and families.
- Communities need information and incentives to partner with pediatricians and others dedicated to the health of children in a more comprehensive and collaborative team-based approach to care. All stakeholders should examine how effectively they reach families and children who need services and work together to close gaps in resources.
As the evidence mounts toward better understanding of the influences of social determinants of health on outcomes, as well as the interdependence on mental and physical health, it’s becoming increasingly apparent that pediatricians cannot do this work alone. We are an integral part of, and uniquely qualified to serve as leaders of team-based care, but we must look at the broader landscape to work with others to give children and families what they need and deserve.
Dr. Kressly is a lead author of the policy and a member of the AAP Task Force on Pediatric Practice Change.
