The United States spends 40% more per patient than other developed countries but suffers the worse overall Health outcomes. There is general consensus that a major solution lies in better managing and preventing adult chronic diseases such as diabetes and heart failure. But starting in adulthood is too late. Many adult health care outcomes are shaped in childhood. This means that the effort to improve those outcomes must begin in childhood. Radically new models of holistic pediatric primary care — which such organizations as Johns Hopkins Children’s Center Harriet Lane Clinic, the Harlem Children’s Zone, and Nationwide Children’s Hospital’s Partners for Kids accountable care organization are pioneering — can play an important role.

There are four major unhealthy behaviors that lead to adult disease: using tobacco, overly consuming alcohol, having a poor diet, and being physically inactive. So-called adverse childhood experiences (e.g., psychological, emotional, or physical abuse) also contribute to adult mental illness and numerous other adult chronic diseases. And adverse living conditions and poverty are perhaps the most pervasive negative influences on adult health, leading to 20% to 50% higher adult mortality even when, in adulthood, individuals are no longer living in poverty or in polluted or unsafe environments.

Current models of pediatric primary care do little to address these “non-medical” causes and consequently have been largely ineffective in preventing adult disease. Reforming primary care pediatrics therefore has great potential for improving overall U.S. health care outcomes. The goal should be to keep children on a trajectory to becoming productive, successful, healthy adults rather than just treating them when they are sick. We need new models of pediatric primary care with the following features:

Comprehensive and team-based. Pediatric primary care must explicitly and comprehensively address not just children’s medical health but also their unhealthy behaviors, social and physical environment, and socioeconomic status. To be successful and cost-effective in holistically addressing children’s total wellness will require a large team of non-medical personnel with diverse training and skills to work with children and their parents. In addition to the pediatrician, the team should include addiction specialists to address substance abuse, attorneys to address housing or custody issues, behavior-change specialists, case managers, dieticians, medical assistants, nurse practitioners, physician assistants, psychiatrists and psychologists, social workers, teachers and school administrators.

Insight Center

The Johns Hopkins Children’s Center Harriet Lane Clinic in Baltimore is moving toward this kind of comprehensive, team-based model. This clinic offers one-stop shopping for a wide range of services in addition to traditional medical care. These include infant safety and injury prevention, social work, legal advocacy, case management, tutoring, fitness classes, nutrition and lactation, mental health, and dental care. It also has partnered with nationally recognized organizations such as the Reach Out and Read program to improve childhood language and literacy, and Health Leads (formerly Project HEALTH), for assessing families’ additional needs and connecting them to community resources.

Continuous and coordinated. Children and families need to be able to access their care team promptly. They also need continuity so they can form meaningful therapeutic relationships. As a large team cares for patients, clear and efficient pathways for communication and workflows are necessary to ensure the patient experience is as seamless and organized as possible. This integration of care will need to occur longitudinally across a patient’s life as he or she ages; vertically among primary, specialty, and hospital care; horizontally between health systems and between different participating sectors (e.g., education, public health, non-profit); and even inter-generationally between care for parents and children. This means that all the providers a patient sees — from birth into adulthood, in and outside of the hospital, from state to state, and at school, and in the doctor’s or therapist’s office — must communicate and share information simply and efficiently.

The Harlem Children’s Zone in the Harlem section of New York City is striving to provide such care. Established in 1997, it takes a “cradle-to-college” approach in comprehensively serving its geographic community of almost 100 blocks with coordinated services, including high-performing schools and programs for early childhood, tax preparation, family preservation, housing, nutrition, and exercise that tracks 600 goals. Its primary goal is to help children graduate college. The program has shown promising results: One group of participants has experienced greater academic achievement and lower rates of incarceration and teen pregnancy after just six years. It was also the inspiration for the U.S. Department of Housing and Urban Development’s Promise Zones Initiative, which awarded over $30 million last year to grantees to achieve objectives such as developing a complete continuum of cradle-to-career strategies and breaking down silos between community agencies.

Proactive and population-based. Instead of being reactive and treating conditions already present, the objective should be to proactively identify children at risk before they develop a health condition and keep them on the path to wellness. This means primary care pediatricians and other team members are responsible for the wellness of all of their patients every day, not just of the patients who visit their clinic that day. To do so, all members of the team caring for a single patient must track and continuously monitor common measures of total wellness and work toward common goals such as increasing school readiness and test scores; decreasing absenteeism, incarceration, substance abuse and unwanted pregnancy; increasing college-graduation rates and career earnings; and, of course, increasing cancer screenings and vaccinations and decreasing development of chronic disease. The team must develop collaboration strategies to meet these goals, prioritize the needs of complex patients, and tailor interventions to the specific needs of different subgroups.

Population health management in pediatrics has been used successfully by Nationwide Children’s Partners For Kids (PFK) accountable care organization, the nation’s largest pediatric ACO. PFK tracks data across all the more than 20 AHRQ Pediatric Quality Indicators, as well as metrics on utilization, which has led to improved quality of care and cost savings among its Medicaid population of children. PFK is now working on expanding its strategy to address the health needs of children with disabilities. Still, these metrics have yet to include broader measures of wellness such as academic achievement, involvement in crime, or job outcomes (i.e., whether someone is employed and his or her earnings over time).

Health information and other technology. Achieving these essential features will be more easily accomplished with the aid of health information technology (IT), including electronic medical records (EMRs) and population-health-management software. These tools must be customized to the population and integrated across the system. In-person or single-patient visits are not always necessary or best. Technologies hold promise for remote monitoring and intervention. Together with online patient portals, text messaging, video conferencing, telemedicine, and group classes or visits, these tools can help the care team communicate with patients more conveniently, frequently, and efficiently.

PFK has utilized health IT to achieve its goals, customizing its EMR to meet the needs of its care coordinators. The American Academy of Pediatrics recently endorsed new blood pressure guidelines that recommend increased use of blood-pressure-monitoring technologies outside the clinic for children at risk. Although telemedicine has yet to be widely implemented in pediatrics, a recent survey by Nemours Children’s Health System suggests that there’s a growing desire for using it among caregivers.

Financing. New pediatric-primary-care models need to: a) pay for value not volume, and b) fund the entire system of integrated, comprehensive care, not just traditional medical care. In this case, “value” is defined as preventing adult chronic disease and realizing the many benefits of adult wellness (e.g., increased work productivity and income, decreased crime and incarceration, and so on). Payment must be shared among all parties and organizations contributing to the total wellness of the child: pediatricians and hospitals, teachers and schools, and social workers and public health departments. Though the barriers to such a payment structure are many, progress is being made. The fact that certain interventions addressing wellness and non-medical drivers of disease have already shown promising cost-effectiveness and high return on investment is cause for hope. Experimentation will be needed to determine how such holistic pediatric-care programs can best achieve long-term return on investment.

The Centers for Medicare & Medicaid Services (CMS) have been a leader in promoting alternative-payment models nationwide. In adult care, CMS announced in 2015 ambitious value-based payment goals for Medicare, which were achieved 11 months ahead of schedule. In pediatrics, CMS has funded PFK with a $13.1 million Health Care Innovation Award and several other pediatric ACOs have also been formed with the assistance of Medicaid funding. The Affordable Care Act included provisions for a broader Pediatric ACO Demonstration Project; unfortunately, this was never funded.

Many challenges to the widespread adoption of new holistic models of U.S. pediatric primary care remain. Integrating comprehensive services will require significant changes in culture, infrastructure, training, regulation, and financing. Assessing a child’s unhealthy behaviors, social and physical environment, and household poverty will be difficult and will require new measurement tools. Demonstrating value will also be very challenging: The results of intervening in childhood to prevent adult disease will not become apparent for decades.

Therefore, prediction models will need to be developed and validated so payers, policy makers, and the public can be convinced that paying now for more comprehensive care for children, with all the elements above, will save money down the line. The evidence to date, both here and abroad, suggests that it will and that investing in holistic care for children will increase value. On the other hand, if we continue to turn a blind eye to these “non-medical” but critical issues our children face, we will almost certainly continue to have poor health outcomes for adults and high health care costs.