P3.C060: Increasing Pediatrician Partnership with Home Visiting services through Integrated Referrals

Background: In 2015, stakeholders in Sangamon County, IL strategized how to improve outcomes for children age 0-3 years(1). Home visiting (HV) was specifically identified as an available but underutilized service. It is well known that effective early childhood HV programs can improve multiple outcomes for children and families (2). Despite the AAP’s recommendation for HV as part of a “comprehensive early childhood system that actively includes… a medical home,” actualizing this is a challenge, and it was apparent that local pediatricians underrecognized the existence and benefits of most HV services.
Sangamon Home Visiting Education and Referral Team (Sangamon HEART), a collaborative led by the Department of Pediatrics at Southern Illinois University School of Medicine (SIUSOM), is working to address this gap in our community. In 2019, SIUSOM pediatricians united social workers, obstetricians, Sangamon County Public Health, Early Intervention, Healthy Families, Parents as Teachers, Nurse Family Partnership, Early Head Start, and the school district preK program among others and determined that a formal system to inter-refer was an essential need in our community.

References:
1-https://cfll.org/Initiatives-Projects/Continuum-of-Learning
2-https://doi.org/10.1542/peds.2017-2150

Project Description: Sangamon HEART received a grant in December 2019 for the PDG B-5 IRIS for CIHV pilot project to develop an Integrated Referral and Information System (IRIS) community and coordinate referrals among our medical and social service partners. Baseline data collection on current referral processes identified many opportunities for increased collaboration, as only two HV agencies received pediatrician partner referrals, with an average of 11 referrals per month.
In over two and half years since launch in August 2021, Sangamon HEART worked with partners to facilitate over 1000 unique referrals and serve over 700 early childhood families in our community. Partner agencies increased from 5 to 25; average monthly referrals increased to 50. Referral response time is less than 2 days, facilitating faster connections with families.

Discussion: A need was identified for pediatricians to be aware of the many partners and resources available in our community, and advocate for their inclusion in improving health outcomes in early childhood. By forming a collaborative with HV and other early childhood service agencies, and creating an order in the electronic medical record to assist pediatricians in facilitating HV and other social service referrals, we found that utilization of IRIS referrals advocated by medical partners increased >350% since launch. Pediatricians not only became increasingly aware of HV and the benefits for early childhood and beyond, but now routinely refer to HV partners with ease of communication between agencies. HV partners reported increased referrals, quicker enrollment of families, and increased rapport with physicians.

Conclusion: Implementation of a SOM led IRIS program increased referrals for early childhood HV in Sangamon County and increased provider recognition/utilization of social services across a broad spectrum of stakeholders.