Working Together: A Home Visitor and Primary Care Partnership

Dr. Erin Graham, DNP, APRN

The National Nurse-Led Care Consortium (NNCC) provides pregnant and parenting persons in Philadelphia with community public health services through two evidence-based home visiting programs: Philadelphia Nurse-Family Partnership (NFP) and Mabel Morris Family Home Visit Program (Parents-as-Teachers). Our nurses visit families regularly throughout pregnancy and the early years of parenting and help them build a healthy foundation of wellness and resources. While our nurses are a critical part of their families' healthcare team, we believe that, for some families, bridging the care being offered in the home to clinical care settings can further improve their overall health.

For this reason, NNCC partnered with PolicyLab at Children’s Hospital of Philadelphia  to develop the Community Clinical Systems Integration (CCSI) initiative. CCSI is a model of care where our home-visiting nurses’ partner with CHOP primary care providers in assessing the needs of and supporting the health and development of each child. Facilitated by nurse access to their clients’ medical health records, the model improves communication between the pediatrician’s office and nurses and creates continuity of care that increases care team support and broader monitoring of the child’s health.

This shift in how the care team interacts across settings empowers families to recognize that they are an important piece in the decision-making process and increases their trust in health care. Dr. Erin Graham, DNP, APRN, NNCC’s Senior Director of Healthcare Integration who participates in the development of the CCSI initiative, described during the National Home Visiting Summit, what she felt was the greatest opportunity the initiative presents. This project is about finding effective ways to share information and creating less of a burden on all parties, home visitors, health care providers, and most importantly, families.” If we can prioritize the sharing of information as well as the individuals directly involved in the exchange of that information, we’re going to see overall satisfaction and engagement not only in families but also in providers and home visitors.

Anna Bechtel, MPH, BSN, RN

Anna Bechtel, MPH, BSN, RN has been an NFP nurse for five years and started working within the CCSI model two years ago. She shared a story during the Summit of a particular family that saw a big impact on their health. Their story is below, and the sections in bold highlight what CCSI made happen – and would not have happened without the permissions facilitated by CCSI. The names of the clients in the story were changed for patient privacy:

“When she was 8 months old, Jules was underweight and scoring behind on her gross and fine motor milestones. The family had been dealing with housing and food insecurity, and mom Denaya was under so much stress, that she hadn’t taken Jules to the pediatrician in the last 4 months of age. Denaya was worried about Jules’ weight but didn’t know what to do. I spoke to her more and found out that she had been trying to schedule a wellness visit but was having difficulty because she hadn’t shared what was going on with the pediatrician’s office.

With her permission, I emailed the pediatrician with the details of their situation and confirmed with the office that they would see her that same week. Afterwards, I read the note from their visit to see what the pediatrician had documented about their visit and then talked with Denaya to hear her interpretation of it.  Based on the communication from the pediatrician, I then supported the family in getting the high-calorie formula they were prescribed from WIC, helped them get a new SNAP card, and set up a ride to the store to get the items they needed. I was also able to look at the chart and see that Jules was supposed to be getting physical therapy (PT) and occupational therapy (OT) but had missed several appointments. After reviewing the developmental assessment with Denaya and helping her understand more about her daughter’s needs, she was motivated to get Jules back to therapy and we arranged for transportation. Throughout this, I continued to follow up with weight checks with Jules and added those weights to her medical chart so the pediatrician's office could also be informed.

As the family continues to struggle with housing, I have followed them and have been able to keep in continuous contact. Jules is now 16 months old and hasn’t missed any more wellness visits. She has had the necessary surgery required for her care followed up with PT and OT and is now walking on her own. The family is in stable housing and has access to enough food. Throughout this, I was able to update their pediatrician on the progress they’ve been making in between wellness visits, so the care team is all on the same page.”

The CCSI program provided a space for Denaya’s nurse home visitor to work directly with her pediatrician and find the best way to support Denaya and her daughter, despite all the obstacles that stood in their way. With every step made toward Jules's care, the CCSI program reinforced Denaya’s understanding of the complex medical situation and empowered her to make educated decisions for her daughter and family. By working together, home visitors and primary care providers can best serve people like Denaya and their families