AAP Voices Blog

It's Time to Break Down Silos

I recall earlier in my career when the mother of a 7-year-old boy told me about his multiple trips to the principal for misbehavior, and her concerns that her child might have attention deficit hyperactivity disorder. After obtaining consent, I spoke to the boy’s school adjustment counselor, who said for the past year, school staff members have recommended Brian see a therapist.

Later that day, I saw a 16-year-old girl with anxiety and depression. She was previously thriving, but over the last several months Jane had missed school and her grades dropped. After assessing each situation, I gave names of counselors for the families to contact. Three months later, no services were in place and the children faced the same challenges. As a primary care pediatrician in rural western Massachusetts, I was tired and demoralized with how common these experiences became.

I shared these feelings with my friend, a local elementary school principal. She faced similar challenges. A typical day at her school involved multiple emergency radio calls and children spending time in a quiet room, like those on psychiatric inpatient floors. We knew something had to change. Realizing everyone would benefit from breaking out of the traditional silos of health care and education, we started the Southern Berkshire Community Care Coordination program. Guided by the groundbreaking work of Richard Antonelli, MD, in pediatric care coordination, we developed a team-based model of care that supports healthy human development and resilience. The program is executed through coordinated connection of children and families with health care, behavioral health, educational, and social services. Most pediatricians want to communicate with school staff, but without a structure in place to obtain consent and exchange information, the efforts fall flat. We’ve added a framework to care coordination that effectively joins systems, while supporting school and pediatric staff, and increasing access to quality care for children and families. 

Essential components of our model include holding monthly meetings with care coordinators from pediatric practices and school staff. After ensuring proper consent, care coordinators use these meetings and other structures to communicate parental, school, and provider concerns to each other. Information such as school evaluations, current student supports, and behavioral screens efficiently arrive on providers’ desks. Care coordinators arrange provider appointments and additional team meetings as needed.

We prioritize family-directed goals based on the input from schools and providers. We encourage families to join a care team using their trusted relationship with their pediatrician as motivation. Our care coordinators have specific responsibilities to ensure families are the focus, support family navigation through the complex health care landscape, track referrals, and address barriers. Lastly, we established an up-to-date database of referral resources while building referral relationships.

A statement from a school clinician captures the essence of the benefits of the Southern Berkshire Community Care Coordination program.

“Having a direct line of communication and support from healthcare providers is a game changer…. We are no longer on an island; there is a foundation built around families to close the communication gap and partner to provide care as a team.” 

This work has its challenges. Shifting from siloed to team-based community care is not easy. Institutions can be insular and resistant to change. Creating new systems requires investment of time and energy. Many school, health, and community operations are overwhelmed by increased needs of those they serve in the post-pandemic environment. Overworked and under-resourced providers and school personnel can struggle to find the capacity to manage change, but the long-term benefits of these efforts create a strong, more integrated community. 

To address challenges in cross-system partnership, we found the following steps useful:

• Take time to listen and understand challenges others face within and across systems
• Establish school administrative support
• Create a memorandum of understanding that states core values, the scope of the collaboration, each role in the model, and protocols for communication
• Identify key contact people within each organization
• Set a regular cross-system meeting schedule

It also helps to start with a pilot that shows benefits of the model in a way that makes others want to join the effort.

Funding and sustainability are hard to secure. While cross-system collaboration enhances care, it can be hard to identify how to share financial responsibility. Is this a school project, a medical system effort, or a community effort? It is promising that some health care systems are beginning to recognize the value of pediatric care coordination. While we wait for adequate reimbursement, we continue to search for creative solutions to funding challenges. One solution came from local legislators in Massachusetts, which resulted in state funding to expand our program to additional school districts. 

I am glad to say with community care coordination in place, I am no longer tired and demoralized during my office days. Instead, I am invigorated and joyful to be part of a team effectively assessing, supporting, and connecting children with fundamental services.