The risks to children's well-being are accelerating because, in part, of an increasingly porous social safety net. Pediatricians are being asked to bear an ever-increasing burden for helping children and families address a myriad of issues, and they have become the providers of last resort. As the distance between what we should do and what we can do as clinicians widens, so too does our frustration and willingness to consider addressing yet one more issue. We often retreat to the comfortable world of otitis media and immunizations and shut out the loud cacophony of the outside world and its effects on our families. We need a new model of care, based on an ecological approach to child health consistent with Bright Futures,40 which provides child health supervision guidelines. To meet these needs, some settings may develop models in which skilled professionals can provide advocacy services, parental health, parental mental health, and child development services in the context of pediatric practice. Although most practices or clinic programs will not have the space or resources to include all of these services, the development and implementation of any one of them will enrich the care of children and families. Other services such as legal aid, family literacy, and mental health may be available in the community and could be colocated in the pediatric setting as outreach efforts on the part of these programs or linked in a manner that ensures accessibility. Similar enhancements to primary-care programs for special groups of children at risk, including those who are homeless, drug exposed, in foster care, and born to teen-age mothers, are being developed in many communities.
The cost of such services presents difficult obstacles. However, given the progressive growth of prepaid practices and competition among plans for patients, services such as those provided by a child development specialist might increase the attractiveness of the plan and allow recruitment of more families. Reducing cigarette smoking, preventing unwanted pregnancy, and reducing drug and alcohol use have potential cost-saving implications that will interest managed-care programs. On the other hand, health care plans may limit services if potential financial benefits are uncertain or acrue to another sector such as schools. For populations at risk, especially health-education collaboration of this type (whether funded and/or cofunded with funds from federal or state department of education budgets, Medicaid, managed-care contracts, tobacco tax revenues, and/or federal family planning funds) should be pursued.
Most of the services we have described are, in fact, already available in most communities and/or health plans. Without new net costs, it may be possible to reallocate some or all of these services to the pediatric primary-care setting in a single-site, one-stop-shopping model. Redeploying services to the pediatric primary-care setting may increase accessibility to these important preventive services and improve the health and well-being of children and their parents.
Chronically ill patients’ self-management abilities to maintain overall well-being: what is needed to take the next step in the primary care setting?
