Guiding Principles for Team-Based Pediatric Care

Abstract

The American Academy of Pediatrics (AAP) recognizes that children's unique and ever-changing needs depend on a variety of support systems. Key components of effective support systems address the needs of the child and family in the context of their home and community and are dynamic so that they reflect, monitor, and respond to changes as the needs of the child and family change. The AAP believes that team-based care involving medical providers and community partners (eg, teachers and state agencies) is a crucial and necessary component of providing high-quality care to children and their families. Team-based care builds on the foundation of the medical home by reaching out to a potentially broad array of participants in the life of a child and incorporating them into the care provided. Importantly, the AAP believes that a high-functioning team includes children and their families as essential partners. The overall goal of team-based care is to enhance communication and cooperation among the varied medical, social, and educational partners in a child's life to better meet the global needs of children and their families, helping them to achieve their best potential. In support of the team-based approach, the AAP urges stakeholders to invest in infrastructure, education, and privacy-secured technology to meet the needs of children. This statement includes limited specific examples of potential team members, including health care providers and community partners, that are meant to be illustrative and in no way represent a complete or comprehensive listing of all team members who may be of importance for a specific child and family.

The Impact of Racism on Child and Adolescent Health

“…[152][153][154][155] • Integrate active learning strategies, such as simulation 156 and language immersion, 157 to adequately prepare pediatric residents to serve the most diverse pediatric population to date to exist in the United States 158 and lead diverse and interdisciplinary pediatric care teams. 159 • Advocate for policies and programs that diversify the pediatric workforce and provide ongoing professional education for pediatricians in practice as a strategy to reduce implicit biases and improve safety and quality in the health care delivery system. [160][161][162] Optimizing Systems Through Community Engagement, Advocacy, and Public Policy…”

Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening

“…Communication between a member of the medical home staff and these professionals on the child's development is, therefore, a critical part of surveillance to ensure optimal care and coordination of efforts and activities to optimize the child's development. [64][65][66] When screening or evaluation is performed by another professional, these results must be shared and discussed with the parent and the pediatric health care professional, including the test performed and the results obtained. The "Birth to 5: Watch Me Thrive!"…”

Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families

“…Additional key partners may include care managers, family navigators, social workers, psychologists, professional interpreters, and public health and social service agencies. 131 Access to comprehensive care for CYSHCN through a medical home is associated with improvements in health status, access to care, and family satisfaction. Use of a medical home approach is also associated with fewer missed school days for children, issues with child care, missed days of work, and out-ofpocket costs for families.…”

“…3,130 Interventions may include counseling about familyfocused physical activity guidelines, good nutrition, and improved sleep routines. 36,131 Common elements among psychosocial interventions include the use of motivational interviewing strategies to communicate hope, empathy, and loyalty; use of plain language; asking permission to ask questions or share information; and partnering with families. 130 Such elements have been found to be effective in building alliances, increasing disclosure, and facilitating discussions about psychosocial strengths and concerns.…”

“…36 A team-based approach may include the use of designated staff for wellness promotion, collocation of services (eg, social workers and psychologists), or referrals to community services for mental health assessment, counseling, and interventions. 131 Behavioral health integration has been described as a useful "approach and model of delivering care that comprehensively addresses the primary care, behavioral health, specialty care, and social support needs of children and youth with behavioral health issues in a manner that is continuous and family-centered." 148 Behavioral health integration can aid the medical home as needs occur from infancy through adolescence and into young adulthood.…”