Pediatricians should always address concerns brought up in a visit. Having a list of referral partners and organizations to connect patients and their families is a good start. Below are resources that families can connect to within the practice and at the community-level, as well as information into how to better incorporate referrals within your workflow.

On This Page:

In Your Practice

Team-based Care Video


Team-based Care Best Practices - These best practices include tips for fostering a strong team-based care culture in a pediatric practice from Transforming Pediatrics for Early Childhood (TPEC) practices with integrated family partners, family specialists, social workers, and mental health providers. 

Early Childhood Team-Based Care Billing Support - Guidance on team-based care billing administration and decision-making for pediatric practices that include community health workers and/or integrated licensed behavioral health providers.

Team-based, Integrated Mental Health Care Billing and Coding Guide - A comprehensive list of billing codes includes descriptions for various aspects of team-based billing for early childhood development experts, including integrated care, the Collaborative Care Model, codes for health centers, and community health worker payment.
 
Use Community Health Workers in Pediatric Primary Care

  • Community Health Workers in Pediatrics Best Practices - A summary of best practices including creating flexibility in role definitions and certification, expanding Medicaid payment, and training recognition pathways.
  • NASHP State Community Health Worker Map – See how states are defining, training, certifying, and paying for the CHW services.
  • Community Health Worker Billing and Workflow Support - a case study on how community health workers were incorporated into Pediatrics Northwest’s care team, including how the team supported billing. It also includes a questions-and-answers summary with state- and community-level teams working to increase access to early childhood developmental services in pediatric settings. 

Co-Management in Primary Care


Reach out and Read: Reading together furthers language acquisition, promotes brain development, and provides an opportunity for families to build powerful, lasting bonds. Reach Out and Read is a national early literacy program serving more than 4 million children annually. This model can be implemented within well child visits and boasts 40,000 pediatric clinician participants.

HealthySteps: is a population-based model aimed at streamlining and enhancing implementation of AAP Bright Futures recommendations. It includes screening for children’s social-emotional and behavioral needs and family needs including social drivers of health. This model employs specialists to provide child development and family support. Healthy Steps has been shown to strengthen social emotional development and improve family knowledge of infant development. 

Promoting First Relationships in Pediatric Primary Care: is a training program at Parent-Child Relationship Programs at the Barnard Center, at the University of Washington. This program promotes children’s social-emotional development through responsive, nurturing caregiver-child relationships. Home Visiting, Child Care and Pediatric clinic-based models are offered training models.

Play Read VIP: is an evidence-based parenting program that uses videotaping and developmentally appropriate toys, books and resources to help parents utilize pretend play, shared reading, and daily routines as opportunities for strengthening early development and literacy in their children. VIP sessions take place in pediatric clinics on days of routine well-child visits, and at each session families meet individually with a VIP Coach for approximately 25 minutes.

In Your Community

Help Me Grow: is a system model that builds on existing resources to develop a comprehensive approach to early childhood system building in communities. Successful implementation of the Help Me Grow model requires communities to identify existing resources, think creatively about how to make the most of existing opportunities, and build a coalition to work collaboratively toward a shared agenda. See if your state is part of the Help Me Grow affiliate network.

Infant and Early Childhood Mental Health Consultants: Early childhood mental health consultants are professionals with mental health expertise who also have knowledge, and experience related to working with young children (birth to five) and their families. Some mental health consultants, referred to as infant mental health specialists, have specialized training in working with families and very young children, birth to three years. Find more including how to connect with mental health consultants at the Center of Excellence for Infant and Early Childhood Mental Health Consultation.

Infant Early Child Mental Health Consultation is a prevention-based service that pairs a mental health consultant with families and adults who work with infants and young children in the different settings where they learn and grow, such as child care, preschool, and their home. The aim is to build adults’ capacity to strengthen and support the healthy social and emotional development of children―early and before intervention is needed.

Early Head Start and Head Start: Early Head Start and Head Start programs support early relational health of children and families through daily interactions, welcoming and safe environments, home visits, and family supports. These programs often employ infant and early childhood mental health consultants.  in your community. Find a local Head Start program in your community.

Maternal, Infant, and Early Childhood Home Visiting Programs: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program supports pregnant people and parents with young children who live in communities that face greater risks and barriers to achieving positive maternal and child health outcomes. Home visitors and families develop strong relationships and trust through meeting regularly and addressing families’ needs. Find more about MIECHV home visiting in your state.

Home visitors:

  • Support healthy pregnancy practices
  • Provide information on topics such as breastfeeding, safe sleep, preventing unintended child injuries, and nutrition
  • Encourage early language development and early learning at home
  • Teach positive parenting skills like reading, playing, and praising good behaviors
  • Work with caregivers to set goals for the future, continue their education, and find employment and childcare solutions
  • Connect families to other services and resources in their community

Learn more about how to build relationships with home visitors from this resource created by the Vermont Department of Health.

View

Therapy Interventions and Supports

Four commonly used evidence-based dyadic psychotherapies for young children include the following:

  • Child-Parent Psychotherapy (CPP); ages 0 to 5-years-old
  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), used primarily for young children with trauma; ages 3 to 18-years-old
  • Parent-Child Interaction Therapy (PCIT) ages 3 to 7-years-old and Child Parent Relationship Therapy (CPRT) ages 3 to 8-years-old, used mostly for children with behavioral issues

For more information see the AAP Mental Health Toolkit.

To find therapy, try your local academic medical center, Association of Infant Mental Health, state centers for evidence-based practice, Child Psychiatry/MH Access Program.

Additional support modalities include:

  • ChildParentPsychotherapy.org
  • CircleOfSecurity.org
  • IncredibleYears.com
  • PCIT.org
  • TripleP-parenting.com
  • Joinvroom.org
  • Caregiver anxiety depression apps (eg, Canopie)

Resources:

Referral and Linkage Workflows

Identifying and Tracking Developmental Needs - Pediatric care teams can use this planning tool to identify, track, and proactively support families with complex developmental and psychosocial needs through a structured, yet adaptable, process.

Screening and Referral Checklist and Strategies Part 1: Processes for Pediatric Practices - Use this readiness assessment checklist to identify gaps and opportunities for creating internal processes for care coordination and referrals.

Screening and Referral Checklist and Strategies Part 2: Strengthening Relationships with Referral Partners - implementation guidance for how pediatric practices can build relationships with external partners to support referrals.

Referral Resource Directory

Completing this worksheet will help you identify local resources and supports in your community.

Download

Referral Directory Templates (Word) (Excel) - Worksheet to guide practices in identifying resources available in the community to assist families.

Define how to document screening/assessments, discussions, risks, and referrals. Enhance your office systems (eg, scheduling, EHR, protocols, etc.) to include improved documentation. Train staff on new systems and protocols. Review chart data for QI to measure improvement over time.

Webinar: How to Identify and Track Complex Needs Slides and Team Planning Worksheet

Last Updated

10/13/2026

Source

American Academy of Pediatrics