Promising Practices: Family Health Centers of San Diego (FHCSD) - California

A Coordinated Approach

FHCSD offers a wide range of services that cover the age span including primary care for both adults and children, reproductive health, mental health, pharmaceutical, vision, dental, elder care and urgent care. Within the system of care, staff address the needs of the entire family using an integrated approach. Staff embrace the perspective that a child’s health is impacted by the health of those who care for them. From the moment a pregnant person first enters the practice, staff from multiple specialties that may interact with the family collaborate to support the journey of a family through their services. The team takes a broader perspective of each individual child, learning and reflecting about their home, community, and circumstances to ensure they are considering each family’s psycho-social needs. By using a family- and child-centered approach to services, teams identify integrated solutions that really address family needs. Long-standing relationships with partners throughout the community ensure that families can access needed resources. In addition, FHCSD works through different externally funded programs to support early childhood development, including the Healthy Development Services (HDS) program that addresses mild-to-moderate developmental and behavioral needs of children birth to 5 years of age.  

FHCSD uses patient assessment and a tiered system of support to identify each family’s needs and promote access to services for optimal health. Staff utilizes different tools to assess for mental health, social drivers of health and adverse childhood experiences upon first meeting a family and during specific well child health visits. Families who screen positive on the Pediatric ACEs and Related Life Events (PEARLS), families who receive a referral for infant mental health and families who are referred to the HDS program are all assigned a care coordinator to “walk beside them” as they receive services within FHCSD sites. The care coordinator processes referrals, contact providers, and support ongoing communication. These professionals often have a bachelors or masters in a human service and education related content while also possessing the demeanor necessary to engage and support families in efficient and effective care. Once hired, staff are trained in building relationships and understanding family needs, as well as the systems within the organization that support integrated services. Care coordination services expanded connections among health providers throughout FHCSD including family support specialists, wellness coaches and other professionals.

Through care coordination services, FHCSD identifies mental health needs and provides more intensive mental health supports to families. For example, as staff worked with families in parenting groups, they identified parental mental health needs that required a higher level of service. FHCSD partnered with a local infant mental health expert to provide dyadic therapy for identified parents. Soon thereafter, the HDS program at FHCSD launched a pilot to address maternal mental health. Pilot services included the administration of the Patient Health Questionnaire (PHQ) tool in both early intervention and 2 pediatric clinic sites. Staff use the tool to identify mothers that are eligible for services including clinical assessment, individual therapy, dyadic therapy, support groups, care coordination, psychiatry and medication support. Maternal depression screening soon was initiated at all FHCSD pediatric clinic sites during specific health supervision visits. In addition, staff asks families questions during health visits to understand social and emotional health concerns and identify family stressors.

Systems that Support an Integrated Approach to Services

FHCSD promotes an integrated approach through various systems that ensure all staff access, know and use critical information to provide high quality care. Initially, a team of FHCSD managers and providers participated in a national training related to Trauma Informed Care. Subsequently, staff training was initiated on a site-by-site basis on Adverse Childhood Experiences (ACEs) to align with the statewide ACEs initiative and integrate screening into everyday practice. Staff access ongoing professional development that includes motivational interviewing, care coordination, trauma-informed care, cooperative approaches, and other critical topics to facilitate high quality mental health supports to families. FHCSD provides opportunities to promote medical providers’ ease with ongoing conversations about mental health, social drivers of health and following up on referrals. Staff participates in ongoing formal meetings and informal communication to share information and identify solutions for families.

Referrals to a diverse array of services are easily made through the Electronic Health Record (EHR) system. The system is purposefully built to enable each provider to have information critical to promoting wellness. FHCSD’s information technology (IT) department works closely with staff to develop and manage a complex EHR system with workflow technology. Collaborating with IT, providers describe each detail of a process that they conduct within their work with families. IT uses the detailed step-by-step process to build workflow systems within the electronic record. The system includes specific patterns, reports and “ticklers” or “flags” to help physicians use specific content to promote a consistent, nonjudgmental approach to identifying and addressing mental health concerns with families. Algorithms and resources are programmed within the system to ensure staff have access to the tools they need to support families. A referral module and scheduling program are also integrated in the system so that all referrals and schedules are tracked and managed. Additionally, chart review is a regular practice staff engage in, using the system to gather and share information across providers to make sure referrals are made promptly and staff can track services to follow up with families for ongoing support. Permission for information sharing is gathered as families enroll and is integrated within the workflow technology when referrals are made to external providers. Changes to adapt or improve the system are easily executed since FHCSD developed its own Meaningful Use Stage 3 EHR system in 2010.

FHCSD’s administration is deeply focused on the provision of exemplary care, consistently thinking about how to use innovation to support quality improvements. FHCSD leverages robust Grants Management and Research Institute infrastructure to identify and secure external funding, and to implement innovative strategies to serve children and families. Grants from First 5 San Diego fund the Healthy Development Services program and the Maternal Mental Health program. For the Healthy Development Services program grant, the local chapter of the American Academy of Pediatrics provides county-wide oversight and has intensively supported the integrated approach by providing ongoing trainings and conversations on a wide variety of topics, such as resiliency, trauma informed care and adverse childhood experiences. These administrative investments push staff to think outside the box and fund the intensity of services required to meet the needs of the population.

Lessons Learned

Early and periodic screening is critical to providing optimal care to children and families. Revisiting mental health through ongoing screening and conversation reduces stigma and promotes awareness and treatment. However, identifying mental health needs is not enough. An integrated services approach allows families and staff to see the ways that stress and trauma can impact infant development. Educating medical staff on the importance of integrated services is critical to effective implementation. Experts in infant and child development, mental health and family-centered services can share how integrated approaches support optimal outcomes for families. Training in trauma informed care and ACEs help staff identify and discuss social drivers of health and family mental health needs. Additionally, dedicated, multi-cultural, and multi-lingual staff can build relationships that support the identification of family needs and find culturally appropriate supports for them. Positive relationships lead to open conversations that can help providers support families and empower them to address their own family needs.

One of the primary challenges to addressing parental mental health is engaging parents in services. Parents face barriers to services including different stressors and limited access to resources. FHCSD works with families to identify, understand and address these barriers. In addition, a sophisticated, yet culturally aware system can navigate stigma to engage families and provide services. For example, FHCSD changed their program name from Maternal Mental Health program to Maternal Services Project to further reduce stigma for engaging mothers in the program.

Consistent identification of ways to streamline services facilitates identification and removal of silos. Building relationships between professionals ensures that collaboration and communication about family needs are clear and can be easily addressed. The development and provision of clear protocols to guide the care team supports efficient workflow and makes a provider’s work easier and more effective. FHCSD leverages a robust information technology infrastructure to generate data-driven, actionable insights for program improvement, and to inform highly competitive and well-informed funding applications. Staff often welcome innovation when it enhances their work with families and allows them to gather the information they need in simple, straightforward ways.

Ultimately, pediatric medical home systems need a champion who supports integrated practices and understands the critical role of parental mental health in infant and child development. At FHCSD, the lead pediatrician participated in a fellowship in Parent, Early Childhood and Infant Mental Health and led by example to ensure an integrated approach was implemented within the system. As an advocate for an approach that embraces parental mental health support and integrated services, FHCSD’s champion was able to identify and integrate opportunities for a new way of providing services. Find additional information on the program, including data related to screening and engagement of mothers: Supporting Maternal Mental Health in an Integrative Relational Model