Early Relational

Health
I M P LE M E N TAT IO N GU I D E
A practical implementation guide for pediatric
primary care and public health professionals
 About the STAR Center
The Screening Technical Assistance and Resource (STAR) Center through the
American Academy of Pediatrics is one piece of the Addressing Social Health
and Early Childhood Wellness (ASHEW) initiative which seeks to improve the
health, wellness, and development of children through practice and system-
based interventions.

Acknowledgements
Thank you to our subject matter experts:

Gerri L. Mattson, MD, MSPH, FAAP

Donna O’Malley, PhD, RN

Howard Dubowitz, MB.Ch.B, MS, FAAP

Paul Lipkin, MD

Funding for this project was generously provided by the JPB Foundation.
Introduction
The American Academy of Pediatrics Policy
statement, Preventing Childhood Toxic Stress:
Partnering with Family and Communities to
Promote Relational Health, asserts that safe
stable nurturing relationships (SSNRs) are biological
necessities for all children because they mitigate
childhood toxic stress responses and proactively build resilience. Current
threats to child wellbeing and long-term health, such as widening economic
inequities, deeply embedded structural racism, the separation of immigrant
children from their parents, and a socially isolating global pandemic, make the
AAP toxic (or is it a relational framework) stress framework as relevant as ever.

While pediatric professionals know relationships are fundamental, the concept of early relational health
(ERH) is not as well understood. It describes the positive, nurturing relationships that build and protect the
interpersonal connections and emotional security of young children. ERH builds on decades of research
showing that the negative impacts of childhood adversity and stress can be buffered by strong foundational
relationships and positive childhood experiences.

When supported, valued, and provided the appropriate time and tools, pediatricians and other pediatric
healthcare professionals can effectively promote positive relational health. Such efforts should help
pediatric healthcare professionals advance healthy child development, strengthen families and their
resiliency, and serve as the foundation to community-building and relationships. Pediatricians serve as
catalysts for producing greater social development and unity in the communities they serve. Implementing
community-level frameworks will require healthy, trusting, and robust partnerships with a wide array of local
community partners from multiple sectors (education, social services, and businesses), not only to facilitate
family access to the requisite community interventions but also to coordinate effective advocacy campaigns
to secure both those interventions and family friendly public policies.

Implementing a public health approach to relational health will require changes at the provider, practice, and
community levels, as well as horizontal integration across sectors. Simply put, successfully implementing a
public health approach that prevents childhood toxic stress and promotes SSNRs will require pediatricians to
put relational health at the center of everything they do. This approach will enhance the current work being
done and make practice more meaningful.

The overarching goal of the ERH Guide is to address how pediatricians and pediatric health professionals
can promote early relational health. This includes implementing practice and workflow changes and
creating an equitable office environment which supports building safe stable nurturing relationships with
patients and strong relationships within their communities. By utilizing a public health approach to early
relational health approach in their work, pediatricians can improve care of children across the lifespan and
refocus on what really matters: healthy, positive child development.

Early Relational Health Implementation Guide | Page 3

 Types of Approaches to Examples at the Examples at the Examples at the
Prevention Relational Health Provider Level Practice Level Community Level

Tertiary Repair strained Build the therapeutic Colocate counseling Embrace restorative
or compromised alliance; employ a services (warm justice and social
relationships common-factors handoffs); facilitate, inclusion (over
approach; explain track, and follow-up punitive measures
behavioral responses on referrals offered. and exclusion).
to stress; endorse
referral resources.

Secondary Identify and address Build the therapeutic Universal screening Identify and
potential barriers alliance; surveil for for prevalent barriers address sources of
to SSNRs possible barriers to seen in that practice; inequality, isolation,
SSNRs; champion facilitate, track, and social discord
screening at practice and follow-up on (poverty and racism).
level; endorse referrals offered.
referral resources.

Primary Promote SSNRs Build the therapeutic Provide or support Implement home
by bulding alliance; promote positive parenting visiting; support
2-generational positive parenting; classes; participate extended family
relational skills encourage in ROR, VIP, and medical care leave.
developmentally other programs that
appropriate play. support the dyad.

www.aappublications.org/news at American Academy of Pediatrics

What’s Included
The Implementation Guide contains a wealth of materials to define early relational health (ERH), advocacy
tools, and resources to build quality community partnerships and creating an equitable office environment.
It serves as a guide for pediatricians and public health professionals on how to integrate a public health
approach for early relational health across public health sectors. It includes items such as: key background
articles, resources, case scenarios, and workflow templates for incorporation of office-based strategies,
and trainings.

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Table of Contents

STEP 1: Organizational Leadership and Office

Workflow Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Advocate that health systems, and practice leaders align incentives, time,
and funding to promote universal primary prevention work

STEP 2: Creating an Equitable Office Environment. . . . . . 9

Foster strong, trusted, respectful, and supportive relationships with families

STEP 3: Building Quality Community Partnerships. . . . . 12

Foster strong, trusted, respectful, and effective collaborations with
community partners

STEP 4: Education and Training . . . . . . . . . . . . . . . . . . . . . 16

Implement and support the development and maintenance of safe, stable,
nurturing relationships through an equity lens.

Early Relational Health Implementation Guide | Page 5

STEP ONE:
Organizational
Leadership and
Office Workflow
Changes
IN T HIS SECTION:
Obtain leadership support to help practices
1
implement changes.
Leveraging the instrumental work pediatricians are already doing with a lens to address early relational
health and promote positive responses to toxic stress requires organizational support, time, and tools to
confront the challenge of assessing and addressing families’ psychological needs. Ultimately, the ability
of pediatricians and other pediatric healthcare professionals to connect with caregivers, promote early
relational health and build community supports will benefit and make their work more meaningful.

Pediatric professionals are well positioned to promote safe, stable, nurturing, relationships (SSNRs) by
translating advances in developmental science into effective interventions for the home, clinic, and
community. To that end, practice leadership buy-in, provider and managerial support and staff development
is instrumental to advancing and implementing changes to enhance practice and office workflow to help
children build safe, stable nurturing relationships, and protect them from the damaging effects of toxic
stress. Leadership support is paramount to the success of this work.

At the outset, it’s important to identify a “champion” or clinical leader to work alongside a staff member to
lead the implementation of practice improvements, practice changes and communicating new program
proposals to senior leadership within the office and clinic environment. The work of primary care is carried
out through administrative and clinical workflows, sometimes without the opportunity to reflect on the value
of the workflow. Before approaching leadership with a new idea, it is important to demonstrate how this new
idea will impact processes, including workflow and other implications for staff.

Review the resources below to explore how to identify organizational structure and members of leadership
to support the practice change, identify where in your practice flow you can improve and how to
strategically advocate and support staff time to advance implementation within the office setting.

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I M P L E M E N TAT I O N T O O L S :

Pediatric Practice: Office Workflow Ideas and Examples

What? Part of providing high quality pediatric care is ensuring a positive experience for patients and families.
This is influenced by the ability to access care when needed and an efficient and well-organized visit.

How? The work of primary care is carried

out through administrative and clinical
How to ensure effective patient workflow:
workflows. Overall goals should focus
on improving the overall satisfaction of • Assess how a patient encounter progresses from the
providers, staff and patients. Prioritize patient’s point of view.
changes based on staff, provider, and
• Identify the points of care where staff engage with the
patient feedback information. Understand
patient and prep for the visit. The process can then be
the community needs—socioeconomic,
reviewed as a team (providers, front desk, clinical, and
prior health care availability, customs, and
staff) to identify areas that increase delays.
traditions. Quality of care provided, and
availability are major determinants in the • Patient flow congestion can occur during the check-in
practice’s success. process, provider appointment times, interruptions in
providers’ workflow, documentation practices, cleaning
Who? Obtaining leadership support is
and set up of examination rooms, clinical processes,
paramount to the success of this work. It’s
scheduling, as well as patient checkout.
important to identify a “champion” or clinical
leader to work alongside a staff member • In terms of delivery of care, patient scheduling is one of
to perform the tasks and responsibilities the most crucial operational systems in a practice. For
required when implementing practice provider, staff and patient satisfaction, it is important
changes and communicating new program to maximize patient appointments and minimize the
proposals to senior leadership within the downtime that happens when patients fail to show up.
office and clinic environment.

Scheduling Methodologies:
• FIXED: Appointments are offered every 10, 15, or 20 minutes. When first starting
in practice, it would be better to allow more time in developing relationships with
patients and families.
Streamline Front
O​​ffice ​Tasks • WAVE: In this scheduling method, instead of scheduling 4 patients 15 minutes
apart, all 4 are set for on-the-hour, and the physician sees each one in sequence
of arrival.
Use MAs and RNs a
​s
Flow Managers • MODIFIED WAVE: This method gains the benefits of wave but lessens the
disadvantages of long waits for later appointments.
Optimize Patient
Sc​​he​dules • OPEN ACCESS: The goal is to take care of today’s work today and minimize future
schedules that are already booked.

• MODIFIED OPEN ACCESS: This is the style common for small practices especially
for those issues parents feel are urgent yet allows the parent to select a
preventive care appointment that is convenient for themselves and their child.

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Implementation and Change at the Practice Level: “Engaging Leadership to
Support Practice Transformation” by Dr. Sara del Campo de Gonzalez, MD, FAAP
What? Organizational levels and members of leadership that
need to support the change. The Preparation:
• Identify strategies for determining organizational level • Workflow mapping helps you
and leadership team to approach for support, as well as “see” your processes in a way
where in the structure or practice flow the change needs that helps give you a better idea
to be made. of the experiences of families,
staff, providers, and community
• Outline components of a practice change proposal to practices as they engage with
present to leadership, including steps for preparation of your practice.
practice environment and comprehensive implementation
• Community Asset Mapping to
plan, which includes the vision statement, goals
inform about the strengths and
and objectives.
resources of a community.
• Outline a plan for keeping leadership updated
• Preparation on individual practice
regarding progress on practice change goals, as well as
environment to implement a
sustainability needs.
practice change proposal.
How? Determine where in your practice flow you will propose
the practice change should be implemented.
The Plan:
• Which steps in your practice change will require a change
• The Vision Statement, Goals,
in organizational infrastructure or leadership support?
Objectives
• Identify at which level of organization/infrastructure the • Timeline
change would need to be made?
• Team Leads/Champions
• Who are the members of leadership to approach • Assessment and evaluation
for support?
• Stakeholder engagement
Who? Communicating progress to leadership by adapting the
• Sustainability, Budget
project planning tool/project proposal summary to illustrate
goals, progress, as well as to communicate ongoing needs
and sustainability goals is imperative to the success of any
The Ask:
practice transformation.
• Highlight the issue.

• High level overview of project

Office Templates planning tool.

• Communicating Progress and Presenting to • Appeal to priorities of

Leadership Template leadership team.

• Propose solution with

• Project Planning Tool Template
contributions from Community
• Resource Guide Asset Map and Workflow Map.

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Step Two:
Creating an
Equitable Office
Environment
IN T HIS SECTION:
Creating a welcoming environment; improving
communication with families and colleagues.
2
Both the physical environment and the “warmth” of the environment impact how
a family feels when interacting with their pediatrician. This includes the practice space as well as the
communication style the care team uses and non-verbal cues that are given throughout the visit. A
welcoming environment is the responsibility of not just one provider but the entire care team. The clinic
integration of co-located services such as behavioral, mental health, case workers and community health
workers help address all aspects impacting a families need. For example, when engaging with bilingual
families, simply understanding concerns such as those around child’s language development and
encouraging utilizing all languages to promote cultural sustainability can begin building trust between the
provider and parent(s).

Creating an office culture that engages staff around race and ethnic equity can help establish a sense of
psychological safety encouraging more individuals to be honest about their experiences. This supports
ERH and the ability to improve communication with families and colleagues. Intentional engagement to
integrate health equity will build staff comfort not only with each other but communicating with patients.
Practice culture that encourages colleagues to have these discussions will promote alignment and shared
understanding around the racial and ethnic equity. This shared understanding can lead to changes that
positively impact patient care such as the standardization of toolkits utilized, improved care team member
integration, screening templates introducing racial equity across age groups, and standardized note taking
for providers. For parents to trust, pediatric providers need to listen and understand parental concerns and
beliefs before making recommendations. Communication could be further enhanced by cultural humility,
implicit bias training, a more diverse health care team (eg, providing families and patients the opportunity
to seeing themselves reflected in the sex, ethnicity, and cultural backgrounds of the team members), and
access to professional interpreters.

This work cannot be done in silos and ongoing engagement of patients and community organizations is
vital. The integration of patient feedback looks like engaging with a family advisor to help providers get
another perspective on ways to make the patient experience not only positive but also equitable. Parent/
family advocates or advisory boards can work as the linkage for the care team and the patients being seen.

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When building a family advisory board, the group makeup and support mechanisms should be part of the
discussion. As assets, they can identify changes to make such as improvement or redesign of forms (eg
Intake, family communication strategies, transition planning, framing messaging around race and ethnic
equity, and well child office environmental assessments. In the absence of this, periodically asking for
feedback during an existing or new process is helpful in identifying changes that should be made.

Review the resources below to explore how to identify where changes can be implemented to support an
equitable environment.

I M P L E M E N TAT I O N T O O L S

Building Equitable Systems: EHR race, ethnicity, and language (REAL) data
What? The collection of REAL data can be helpful in helping to
identify inequities in care across patient population but only if Examples of changes the
accurate data is being examined. Data collection can occur via examination of REAL data
various platforms or on paper, but it is helpful only if there is a can bring forth:
designated role examining and sharing out reports with necessarily
staff members. • Identification of interpreters
needed for patient population
How? A needs assessment looking at patient population can to support health literacy
help bring forth what changes need to be made to improve the • Identification of improvement
patient experience. for screening tools (e.g.
Who? For data this is being collected by a care team member, Edinburgh postnatal
discussions should include what data would be helpful in depression scale (EPDS),
supporting providers in providing the best care. Particularly Survey of well-being of
looking at the demographic information being collected and if that young children (SWYC),
accurately speaks to and breakdown the patient population. If data Developmental screenings
is being collected by the larger system that a practice is a part of, • Integration of screener into
one can utilize data that is accessible or pull-out relevant data to EHR system
the practice to begin building out a better understanding of the
patient population.

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Words Matter: How Language Used in Health Care Settings Can Impact the Quality of
Pediatric Care
What? This webinar will examine the impacts of conscious and unconscious provider bias, particularly as
expressed through written and verbal communication. Speakers explore the power of language in medical
settings and its impact on health disparities for historically stigmatized groups and share opportunities to
improve trust between patients, families, and care providers.

How? Explore the power of language in medical settings and its impact on health disparities for historically
stigmatized groups and share opportunities to improve trust between patients, families, and care providers.

Speakers raise the issue of significant disparities in health care quality experienced by people of color, and
discuss the importance of recent research related to language, bias, and empathy in patient care, including:

• The Link Between Stigmatizing Language and Patient Care

• Opportunities to Build Trust Between Patients, Families, and Providers

• Increasing Awareness Among Pediatric Providers

Who? Pediatricians and public health professionals can stay aware of and avoid including language that
reflects personal frustration or negative judgments; strive for testimonial justice by being thoughtful,
reflective and check assumptions; try to include reasons for nonadherence and think carefully before
using quotes.

Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?

Mistake/Inaccuracy
Diagnosis Not Discussed
Errors and Did Not Happen In Visit
Confidentiality Concern Surprises
Lie (Intentional)

Obesity
Condescension
Gender/Sexuality
Not Heard/
Misquoted Disrespect Labeling Personal
Clinical Language/ Judged & Descriptors
Conventions
Offended Other stigma

Assorted
Other 1 in 10
Research: Leonor Fernandez, Alan Fossa, Themes respondents reported feeling
Zhiyong Dong, Tom Delbanco, Joann Elmore,
Patricia Fitzgerald, Kendall Harcourt, Jocelyn judged or offended.
Perez, Jan Walker, and Catherine DesRoches

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Step Three:
Building
Quality
Community
Partnerships
IN T HIS SECTION:
How to assess and build quality community partners.
3
Pediatricians and public health professionals are well positioned to promote safe stable
nurturing relationships (SSNRs) by translating advances in developmental science into effective interventions
for the home, clinic, and community. Pediatricians and advocates are expanding their efforts to translate
research into communication strategies that convey healthy and positive child development emerges best
in the context of nurturing, warm, and responsive early parent/caregiver- child relationships, surrounded by
safe communities with strong trust and social connectedness. Building positive early relational health does
not just happen in an office visit, and does not just happen in the home, but also happens in the context of
a safe and supportive community. By making early relational health a key piece to promote healthy, positive
childhood development, pediatricians can further expand and build quality partners to intentionally enhance
their level of care.

The American Academy of Pediatrics Council on Community Pediatrics published a policy statement in 2013,
in which they addressed the imperative for pediatricians to address the needs of their patients, families and
communities across the spectrum, from the individual to the broader community. Community pediatrics is
the practice of promoting and integrating the community pediatrics, child advocacy, public health, social
determinants of health, positive social, cultural, and environmental influences on children’s health as well as
addressing potential negative effects that deter optimal child health and development within a community.
To do so, pediatricians must successfully merge their traditional clinical skills with public health, population-
based approaches to practice, and community advocacy.

Community pediatrics and organization engagement occurs through finding and building relationships
to help meet patient’s needs. Partnerships that are beneficial in addressing resource referral needs can
be food banks, other health systems, childcare needs, early learning hubs, local and regional coalitions,
school resources. It is important for providers to expand their network to include community leaders and
organizations. Building these relationships help address disparities that exist as barriers to families getting

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their needs met. Including this as an integral part of practice, pediatricians and public health professions can
gain the following:

• A perspective that expands the pediatrician’s focus from one child to the well-being of all children in
the community.

• A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political
forces affect the health and functioning of children.

• A synthesis of clinical practice and public health principles to promote the health of all children
within the context of the family, school, and community

• A commitment to collaborate with community partners to advocate for and provide quality services
equitably for all children.

Review the resources below to explore how to identify and build quality community partners.

I M P L E M E N TAT I O N T O O L S

AAP Community Health and Advocacy Tools and Training Modules

What? To support and empower pediatricians and public health professionals to effectively address
child health needs in their communities through partnerships and advocacy and by equipping them with
actionable and effective content and tools.

How? By understanding the benefits of working in partnerships and how to identify other people,
organizations, or institutions that are working on similar issues. Working in partnerships helps pediatricians
increase the number of people and groups working to improve children’s health and well-being and
builds strength.

Community partnerships address Educational Objectives Upon Completion:

and consider the environmental
• To help pediatricians identify common allies and
and social factors influencing
partners; explore the potential roles pediatricians
child health, such as:
can play within these partnerships and how
• Exposure to violence partnerships can help them achieve their advocacy
goals within a community.
• Safe places to play

• Poverty • To increase pediatrician advocacy-related

confidence and comfort level in working
• Child abuse
partnerships.
• Access to healthy foods
• To demonstrate that working in partnerships to
• Transportation
accomplish an advocacy goal is doable and can fit
• Quality learning environments within the demands of a busy schedule.

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Utilizing a Bull’s Eye Worksheet
What? A simple bull’s eye worksheet can help prioritize who can easily be approached to get involved in
community-based projects to advocate on behalf of issues specific to children’s health and well-being.

How? Below are three important steps to assist with completing the worksheet and building a coalition of
individuals to collaborate with.

• Consider 3-5 individuals and groups with whom you have a direct connection and already know would
be supportive of your issue. Write those down in the first ring of the Bull’s-eye. These people are your
“base.” These are the first people to ask to get involved.

• Think of “the next layer out” of individuals and groups – people with whom you have a direct
connection, who might be interested in your issue, but are more distant than your base either because
their connection is weaker or because the issue is less relevant to them. Write 3-5 groups that fall into
this category in the second ring of the Bull’s-eye. These people are those you can ask to get involved
once you have secured your “base.”

• Individuals and groups you would like to see involved, but don’t necessarily have a direct connection
with. These groups could include unlikely partners. Write these groups in the third and final ring of
the Bull’s-eye.

YOU

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AAP Community Pediatrics Training Initiative
What? Define an issue that you wish to explore, build expertise by thinking through the process, and practice
the skills necessary to build collaborative partnerships with a community to advocate for children.

How? By developing a coalition of individuals and groups that can help you plan and implement ideas to
achieve the overall goal. When planning and implementing a community-based project, it is very important
to work in collaboration with others in the community to accomplish a great deal more.

The Preparation: Explore Existing

Resources:
• Identify an area of interest related to child health and
well-being. • What initiatives/projects
already exist or have been tried
• Locate population-level data and conduct a literature review in the past (locally, regionally,
to develop expertise about a particular advocacy topic. and beyond)? It is important
to realize that other experts
• Identify key stakeholders and note key shared values and
may have already explored the
goals regarding a particular issue.
same problem/issue of interest
• Define three measurable objectives as they relate to your and are already involved in
community efforts related to it.
advocacy topic.
• Consider meeting with your
• Develop a plan to impact a community that will ideally lead to
local medical librarian for
a change in your measurable objectives.
assistance with identifying the
• Describe a sample PDSA cycle as it relates to a particular current literature related to
advocacy issue. your specific advocacy issue (or
population) and obtaining the
• Describe your intended role in advocacy as a part of your resources that you will need to
professional role as a pediatrician. build your content expertise.

Who? Identify and connect with the

individuals and content experts who can 10 Steps for Building Community Partners
aid you in developing and implementing and Projects:
your proposed project. These may
1. Identify the problem 8. Work diligently to
include members of local community
accomplish goals and
groups, or even regional or national 2. Define the baseline
objectives
content experts. When identifying these 3. Learn the literature
project “champions” and engaging with 9. Develop tools for effective
4. Explore existing resources
them, consider individuals who are evaluation
passionate about a particular issue or 5. Develop your road map 10. Regularly re-evaluate
patient population that they care about 6. Build a coalition and reflect on plan and
so deeply. project-related work
7. Ensure things are done
WITH the community, not
TO the community

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Step Four:
Training and
Education
IN T HIS SECTION:
Provide learners with the opportunity
to conduct trainings within their own health
care organizations or practice networks to assist with
integrating and supporting early relational health.
4
EQUITY CASE SCENARIO 1

Part 1
Paulo is in clinic for his 18th month well visit. His parents Sonya and Carlos requested their bilingual home
visitor accompany them to the visit. The couple speak Mixtecos and have U Visas. Sonya G5 P5, tested
positive for Covid on admission to the hospital when Paulo was born at 38 weeks gestation weighing 7lb
3 oz. with an Apgar of 8. Sonya and baby were separated after delivery due to an abundance of caution
early in the pandemic. Sonya remained asymptomatic after the vaginal birth and Paulo tested negative for
covid, both were discharged home after a 1 week stay in the hospital. Sonya and Paulo were referred to a
local home visiting program by the promotores who had supported her prenatally. Sonya had breastfed all
her children but was discouraged from breastfeeding Paulo. Sonya works during the day as a housekeeper
at a local hotel. Carlos is the night janitor at the local Catholic school 3 of the older children attend. They
alternate their schedules and can’t afford childcare, have very limited English, and no transportation.

Reflections: When reviewing Paulo’s previous visits, you make a mental note that the family has not missed
any well-child visits, immunizations are up to date, and baby’s growth chart is right on track. As the provider
you also note that the baby/family is enrolled in a local Healthy Families America home visiting program and
receives WIC. Your plan includes complimenting mom and dad on attending all scheduled visits and asking
them if other challenges related to social determinants of health have come up since their last visit.

Part 2
Upon entering the room, you observe Paulo sitting in Sonya’s lap holding onto the soft blanket he is wrapped
in to keep him warm as he is only in a diaper and ready for his exam. The three adults are in conversation,
and all are attentive to Paulo. The home visitor introduces herself to you and explains the parents requested
her to be there to translate. Sonya is worried that she has harmed Paulo by not having him with her right

Early Relational Health Implementation Guide | Page 16

after birth and she regrets not breastfeeding him. She feels guilty for not getting the Covid vaccine earlier
and fears Paulo will not bond with her as well as the other children did. Paulo begins to wiggle and slides off
Sonya’s lap and toddles across the room and raises both arms up and smiles as Carlos picks him up. Carlos
reaches in his pocket and pulls out a small toy car. Paulo takes the little car and slides off dad’s lap down to
the floor and begins to make a motor sound as he crawls across the floor pushing the toy car.

Reflections: Paulo’s physical exam is normal, the ASQ screen shows Paulo is meeting developmental
milestones. You’ve observed Paulo walking, crawling, and interacting with mom, dad, and the home visitor.
Concerns include maternal/paternal depression, social determinants of health, and stressors related to
limited English proficiency/language barriers and cultural beliefs, as well as lack of sleep due to work
schedules. In conversation mom shares again that she is worried that being separated from Paulo and not
breastfeeding his has caused or will cause harm to their relationship. You share your physical exam and
developmental screening findings with the parents. As the home visitor translates the parents’ response
to the good news you’ve shared about Paulo growing and developing well you see mom and dad smiling.
You ask mom and dad if they have other worries to share with you and that you will work with them to help
address any concerns they have. You learn from the home visitor that Paulo and the family will be enrolled
in program until Paulo turns 3-years old and that that Paulo is on a wait list for a spot at a local Early Head
Start program.

Strengths:
Supportive partner, experience parenting, home visitor, social support and strong faith community ties, U
Visas, employment, normal delivery, normal Apgar, warm family relationships observed. Home visitor reports
baby is still in a rear-facing car seat, parents have received safe sleep education and baby sleeps in a crib,
baby gates, cabinet locks, and electric plug covers have been provided, there is a working smoke detector in
the home, no firearms in the house, and medications are kept in a lock box.

Challenges/Concerns:
LEP, lack of transportation, lack of childcare, maternal and paternal risk for depression/anxiety, food
insecurity, and housing and utility needs. Immigration status is always an additional stressor, even for this
family who were issued U Visas because dad was assaulted and badly injured while walking to his night
job. He has recovered over the past year but still receives physical therapy and takes medications for
shoulder and back pain.

Early Relational Health Implementation Guide | Page 17

Test Questions
1. Prior to the visit, how did you prepare for creating a welcoming office environment for Mixtecos
speaking patients?

a. How to elicit strengths from the responses from the family members and support the care
they need.

2. What exercises or community events can you suggest to the mother and baby that will help
strengthen their bond?

3. Ask mother where she’d like to see her relationship with the child at this age. How would she like to
be supported?

4. Is there enough concern in the mother’s behavior to conduct an Edinburgh postnatal depression
screen? How do you plan to communicate these concerns to the family in a culturally
respectful manner?

5. What community supports programs are you aware of that align with the family’s cultural beliefs?

6. What would you have done differently during the well-child visit?

7. Please describe your own reflections throughout the visit.

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EQUITY CASE SCENARIO 2

Part 1
Sofia is a term 3-day-old infant born to mom, Rena, and here with dad today for the infant’s hospital follow
up. Both mom and dad only speak Spanish. Per the hospital discharge summary, Rena had a miscarriage
late in her first pregnancy and is G3P3003 and prenatal labs were all unremarkable except history of anemia.
The discharge summary says mom had gestational diabetes but mom denies this. Mom had a C-section but
Infant and mom went home after 48 hours.

As the provider, you enter the room and notice that dad is watching the baby while sitting in a car seat. Mom
is sitting in a chair across the room. As the provider, you introduce yourself and start to ask mom some
questions about how the infant is feeding, stooling and voiding. Rena is not sure about how to answer these
questions. Rena quickly shares that she is very tired, has a headache and needs some pain medicine. She
says it has been hard with having two other children (3 years of age and 9 years of age) to sleep.

Reflections: Mom seems to have a flat affect, looks exhausted and in pain, and not able to listen during the
discussion. You are worried about mom’s physical and mental health and the impact on the infant and family
dynamics. You plan to do an Edinburgh Postnatal Depression Screening.

You decide to ask specific questions about mom’s health. Rena shares she is worried as she does not have
enough breastmilk and so they are using Enfamil formula. You ask about mom’s intake of liquids and she
reports she has not drank any water all day. You decide to go get two bottles of water and some Tylenol.
You then leave to see another patient and ask the nurse check her blood pressure. When you come back in
10 minutes, you are reassured to see that Rena’s BP is 110/70.

Reflections: You decide to ask a few more questions and mom seems to pay attention a little better.

Mom says infant is taking ready to feed Similac formula 40 ml every 1-2 hours. Mom is not sure how to mix
the formula from powder and asks for some help. You ask if Sofia is spitting up and mom says just twice but
not forceful. You learn that mom is worried because Dad is not finding much construction work and he does
not have insurance. Dad also shares that they do not have enough food. Mom has not signed up for WIC yet.
Mom reports she does not have a crib and has the baby sleep in a bouncy chair.

Reflections: You are worried about many social determinants of health and plan to do a screening later. You
are worried about the several stressors for the family and that could impact the infant’s social emotional
health. You start to examine the infant and notice that dad is very good at talking, trying to make eye contact
with Sofia while undressing her and putting her on the exam table. You praise him for being here at the visit
and that there is a need support mom with caring for the child and healing.

Infant on exam is unremarkable and has mild jaundice to mid-chest and has lost 5% from BW. The umbilical
cord is still present. The infant also has the name bracelet on her wrist. During your conversation about the
infant dad shares that they have no family in the state or country.

Plan: You cut off the wrist bracelet. You bring in an interpreter to help with anticipatory guidance and
education for several items. You talk about trying not to overfeed and space out formula feeding and if
breastfeed do that first and can promote more milk supply. You review mixing of the formula and also to
discuss safe sleep and how to get a crib. The EPDS shows a score of 3 and no suicidal ideation. You screen
for social determinants and mom reports they are not able to get utilities when needed and transportation is
an issues to get medical care in addition to needs for health insurance for dad and food. You make a referral
for care management. You also make a referral for an agency who can provide a crib. Plan is to follow up in
5 days to check weight, jaundice and how mom is feeling and follow up on if can get a crib. Mom agreed to
have infant sleep in a laundry basket instead of a bouncy chair for now.

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Part 2
Sofia followed up at 8 days of age for a weight check and to see how mom is doing. The infant gained 7
ounces. Mom has enrolled in WIC and is now breastfeeding first and then offering Gerber formula if hungry
2 ounces at a time. Mom is mixing 1 scoop of powder in 2 ounces of water which is correct. Infant is voiding
and stooling well. Mom feels like she has much more support. She had a newborn visiting appointment via
Facetime the day before. Infant has a normal exam except for an umbilical granuloma which was cauterized.

Concerns:
Attachment to infant and mental health of mother, dad unemployed, family needs food and transportation,
unsafe sleep, and non-English speaking

Strengths:
Dad is involved and interacting well with infant and trying to support mom; mom has breastfed before; family
has car seat, infant now enrolled in WIC, mom feels supported.

Early Relational Health Implementation Guide | Page 20

Test Questions
1. Prior to the visit, how did you prepare for creating a welcoming office environment for Spanish
speaking only patients?

a. How to elicit strengths from the responses from the family members and support the care
they need.

2. As a provider what interpreter services can contact to prepare for the

3. What is your next plan of action if the screen is positive/if the screen is negative? How would
you manage both scenarios and communicate the screen results in a culturally respectful and
responsive manner?

4. What community resources can you contact to support the family?

5. What is the developmental milestone marker or outcome the child should be recording at this age?
How do you communicate steps to support the family?

6. What would you have done differently during the well-child visit?

7. Please describe your own reflections throughout the visit.

Early Relational Health Implementation Guide | Page 21

Additional
Resources
Organizational Leadership Buy-in

Year Featured Resource Format Description

AAP Resource: Resource The Developmental Screener EHR Implementation Resource was
Electronic Health created to advance a child health framework in electronic health
Information Capacity systems by identifying elements across eight of the most widely
in Pediatrics (EHICAP) used developmental screening instruments for implementation
Project: EHICAP EHR in EHRs. This resource will have broad applicability and be of
Implementation interest to both the pediatric and public health communities.
Resource Roll Up

2021 Capturing Social and Literature Capturing Social and Behavioral Domains and Measures in
Behavioral Domains Electronic Health Records. Standardized use of EHRs that include
and Measures in EHRs social and behavioral domains could provide better patient care,
improve population health, and enable more informative research.

Family-Centered Tool This tool is not designed to provide a score but is meant as an
Care Assessment opportunity for reflection and quality improvement activities
Tool related to family-centered care within outpatient health care
for Providers practices. It can also be used by families to assess their own
skills and strengths, the care their children and youth receive,
and to engage in discussions within health care settings and
with policy makers in organizations, health plans and community
and state agencies about ways to improve health care services
and supports.

2021 AAP Resource: AAP Resources to support care coordination, discover leading
National Center Resource concepts, tools and resources to advance your knowledge
for Medical Home and understanding of the medical home as it relates to your
Implementation: practice transformation.​​
Coordinated Care

AAP Resource: AAP These policy templates are provided as a reference for practices
Practice Resource developing their own materials and may be adapted to local
Policy needs. You should consult an attorney who is knowledgeable
Templates about the laws of the jurisdiction in which you practice before
creating or using any legal documents.

Early Relational Health Implementation Guide | Page 22

Community Partners

Year Featured Resource Format Description

2013 AAP Clinical Report: AAP The medical home process and Individuals With Disabilities
Early Intervention, Clinical Education Act Part C policy both support nurturing relationships
IDEA Part C Services, Report and family-centered care; both offer clear value in terms of
and the Medical economic and health outcomes.
Home: Collaboration
for Best Practice and
Best Outcomes

2014 AAP Policy Statement: AAP Policy This policy statement stresses the importance of care
Patient- and Statement coordination, with guidance for implementation. Coordination
Family-centered Care of care across settings permits an integration of services that is
Coordination: centered on the comprehensive needs of the patient and family,
A Framework for leading to decreased health care costs, reduction in fragmented
Integrating Care for care, and improvement in the patient/family experience of care.
Children and Youth
Across Multiple
Systems

2015 AAP Publication: Road AAP A roadmap to help structure primary care approaches to
Map to Address the these needs through the development of comprehensive and
Social Determinants effective collaborations between the primary care setting and
of Health Through community partners.
Community
Collaboration

2021 AAP Resource: AAP AAP web page that provides links to resources, tools, and
Care Webpage templates that promote effective care coordination. These
Coordination resources are designed to help pediatricians stay current on
Resources healthcare trends.

2017 AAP Resource: AAP Template to facilitate the development of a referral list. Excel
Referral Directory Resource collects more details and can be populated and used as
(Excel) a directory.

AAP Resource: AAP Template to facilitate the development of a referral list. The word
Referral Directory Resource version is more basic and may be appropriate for practices just
2017 (Word) starting out.

2021 Addressing Social Resources Policymakers and health care stakeholders have called attention
Needs Through to the inconsistency and initiated new programs to address
Partnerships patients’ social needs. This webpage consists of resources on
establishing successful referral partnerships.

Early Relational Health Implementation Guide | Page 23

Equitable Systems

Year Featured Resource Format Description

2019 The Impact of AAP Policy The objective of this policy statement is to provide an evidence-
Racism on Child and Statement based document focused on the role of racism in child and
Adolescent Health adolescent development and health outcomes.

2021 Practicing Socially Webinar Dr. Omolara Thomas Uwemedimo, MD, MPH, provides
Responsive personal and professional insights into the importance of social
Pediatrics: Why responsiveness to advancing health equity for racial/ethnic
Health Equity Begins minority children, children in immigrant families, and low-
in Communities Not income families.
Clinics

2022 AAFP EveryONE Toolkit This toolkit offers strategies for use in your practice and
Toolkit community to improve your patients’ health and help them thrive.

2021 Racial Equity in Literature ICMA and the Government Alliance on Race and Equity (GARE)
Action: How to shares the experiences of several city and county managers who
Get Started are using GARE’s framework of normalizing conversations about
race, organizing within government and with community partners
to achieve racial equity, and operationalizing with new policies,
practices, and racial equity action plans.

2022 Health Equity AAP The National Resource Center for Patient/Family-Centered
​ Resource Medical Home developed a health equity logic model, outlining
key activities, stakeholders and anticipated outcomes to support
the increase of African American and Black children and youth.

2018 Health Leads Toolkit The toolkit combines Health Leads’ 20+ years of experience
Screening Toolkit implementing social needs programs with well researched,
clinically-validated guidelines from sector authorities like the
Institute of Medicine, Centers for Medicare and Medicaid Services
and the Centers for Disease Control & Prevention.

2022 Anti-Racism Resource Implements structures, policies and practices with inclusive
Continuum decision making and other forms of power sharing on all levels of
the institutions life and work.

Early Relational Health Implementation Guide | Page 24