Keeping Families Healthy is a program that bridges the gap in pediatric care coordination by employing community health workers to serve as a liaison between families and pediatric medical home clinicians and practices. Most recently, the program won the Academic Pediatric Association’s 2017 Health Care Delivery Award for “its innovation in linking the medical home with the community, engaging learners at multiple levels, and conducting academic work in concert with care delivery to at-risk children.”

Outcomes from the program include a 50% decrease in preventable emergency department visits among program participants compared to a convenience control sample, and improved vaccination rates by 20% in infants and by 16% in newborns compared to a convenience control sample.

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Implementation Insights:

  • Foster partnerships between primary care practices and community-based social wellness organizations to recruit, train, and hire community health workers.
  • Hire and train diverse community health workers that represent and live in the communities they serve.
  • Facilitate home visits by community health workers to enhance care coordination and empower families and caregivers.
  • Develop an information sharing system between community health workers and the primary care medical home to ensure plans of care are shared and communicated with all appropriate clinicians.
Last Updated



American Academy of Pediatrics