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June 2025

Sometimes the most important questions our pediatricians and pediatric specialists ask have nothing to do with medicine.

Just as they screen patients’ hearing, chart their growth, and monitor for signs of illness, pediatricians also ask questions like, “Do you have enough to eat? How is your stress level? How are things going in school?”

Their goal is to screen patients for social needs shown to impact a child’s health. These aren’t problems a provider of medical care can necessarily fix alone, but that’s where our Care Integration team comes in to assist.

Care Integration is made up of care coordinators, care managers, and community health workers who are nurses, social workers, or other trained professionals. Their job is to connect people to the community resources they need. They troubleshoot the kinds of problems that aren’t strictly medical, but that have a big influence on a child’s health and sense of well-being.

Care Integration leaps into action when we learn that a family is at risk of being evicted from their home, or if kids are hungry on the weekends because their only consistent meals are from the school cafeteria. They may assist when a family needs help enrolling their child in Medicaid, when they struggle to find transportation to their appointments, or when it’s cold outside and they need a warm coat. They become expert navigators of state and local government services where their patients live, community groups that offer aid, and the intricacies of Medicaid and other local health insurance options.

Recently, I heard how one of our care coordinators helped a patient family through a difficult period in their lives. It offers a great example of why this work is so needed:

One of our teenage patients — let’s call her Anna — recently visited her primary care doctor. As the doctor spoke with Anna and her mother, it became clear that the family was under intense financial strain.

Anna had sustained an injury while playing sports, and an ambulance brought her to a nearby hospital. The family has private health insurance through dad’s job, but their annual deductible is $5,000. Thankfully, Anna was fine, but after getting an ambulance bill for $1,800, they were struggling just to put food on the table. The injury no longer seemed like their biggest problem.

Research has shown that financial stress and food insecurity are two “adverse childhood experiences” (often called ACEs) that can put children at risk for health problems later in life. Other ACEs include traumas like violence in the home, loss of a family member, natural disasters, or bullying.

You can imagine how Anna’s family might react under the weight of great financial strain: Her parents would be stressed and distracted, and high levels of stress can damage family dynamics in any number of ways. Cutting back on food would only exacerbate the situation, leaving them tired and irritable. It is easy to see how Anna’s grades could slip as she found it harder to concentrate in school.

Luckily for Anna’s family, her pediatrician made a referral to ��ѻ��Ƶ Care Integration team.

In this case, the care coordinator knew of a grant program for people with high-deductible plans run by the family’s insurer and encouraged them to apply. She also connected them to food banks and other community resources that could help until their finances stabilized. She sent this information to the family through the ��ѻ��Ƶ app.

A few weeks later, the care coordinator phoned to check in.

Mom sounded like a 20-pound weight had been lifted off her shoulders. She had applied for the grant and was optimistic they would get it. She had been too embarrassed to reach out to food banks, but with the care coordinator’s encouragement, she did—and got everything they needed. The family was getting back on its feet and felt hopeful for the future.

Most health insurance in this country doesn’t cover care coordination. America’s “fee for service” insurance model pays clinicians for the quantity and complexity of the medical care they provide. Helping a family figure out how to cover emergency bills and put food on the table is not medical care, but it certainly is health care.

Under most plans, the more care coordination health systems provide, the more money they lose. Fortunately, Anna is part of a growing trend where instead of paying for every x-ray, clinic visit, and procedure, insurers are paying clinicians a fixed amount for each child and then offering bonuses if they can keep kids healthy. Some describe it as “accountable care” or “value-based care,” but I think of it as “pay for health.” Health care providers should have a financial incentive to keep kids healthy, not just to heal them when they are sick.

That is the future ��ѻ��Ƶ is creating. We are not waiting for the national landscape to shift —we are leading that shift. Each year, we enroll more and more patients into “pay for health” programs that provide excellent medical care while also incorporating services that proactively address barriers to health.

Care integration is one way ��ѻ��Ƶ addresses the constellation of factors that contribute to a child’s health and wellbeing—what we call Whole Child Health. ��ѻ��Ƶ helps children like Anna heal from their physical injuries and create a healthy home environment to grow and thrive. ��ѻ��Ƶ is committed to partnering with families, community groups, and insurers to achieve Whole Child Health for the patients we serve and for all children in America.