Team-based care for children: Who should be included and who should lead?
Susan J.Kressly, M.D., FAAP
Much has been written about team-based care in the adult literature, but there is
a paucity of information on what this should look like for children. A new AAP policy
statement addresses how team-based care should incorporate what is unique about children
and outlines what is optimally needed to support children and families.
Team-based care for children is different from that for adults for three key reasons:
Early environment and experiences have crucial effects on lifelong health.
Resources targeted toward health promotion and disease prevention have significant
Pediatrics fundamentally incorporates the dynamic nature of childhood.
Medical home ‘plus’
The policy recommends a team that continually works to keep children and their families
or caregivers at the center. In addition, it’s important to think of the team as one
that extends beyond and enhances the medical home, and is dynamic as the child grows/develops
and is responsive to his or her changing needs.
For example, an infant’s team may include the pediatrician, a lactation consultant,
the obstetrician-gynecologist if the parent is depressed and a community home-visiting
program. A troubled teen’s team might include the pediatrician, foster parents, a
child psychiatrist, a school psychologist and a wrap-around service provider.
While team-based statements produced by other entities do not specifically state that
teams should be led by a physician, this policy clearly articulates that pediatricians
are the ideal leaders of team-based care for children. The locus of leadership may
shift over time, residing with the primary pediatric provider or the pediatric medical
or surgical subspecialist, or it may be shared among them when appropriate. Also,
the team’s composition and pediatrician leadership will change as the needs of the
child and family change.
Does this mean the pediatrician must do everything? Absolutely not.
From an operational viewpoint, other members with child and/or adolescent expertise
may be the most appropriate team leaders to oversee and provide details of care delivery.
However, as the policy states, “A pediatrician (general pediatrician, pediatric medical
subspecialist or pediatric surgical subspecialist) is uniquely qualified, on the basis
of training and expertise, to oversee the team, provide administrative oversight and
serve as a resource to promote optimal functioning while meeting the needs of the
patient and family, given available resources.”
No single person or entity can meet the needs of a child and family throughout their
growth and development. Team-based care asks us all to reflect on what we do best
and identify opportunities where others can contribute, then work together toward
a shared goal: to better meet the needs of children and families and help them achieve
Much work is to be done if every child is given the opportunity to be served by a
high-functioning team. These include the following, according to the policy:
Payment models are needed to support appropriate payment for implementation, ongoing
infrastructure, collaboration and continuous improvement to sustain team-based care
for children and families.
Medical school, residency training and continuing medical education need to incorporate
principles and practice of team-based care and development of team leadership skills
for pediatricians. Pediatricians will need education, implementation toolkits, technical
assistance and infrastructure support to transform their practices.
Implementation of technology-enabled communication is needed to establish, support
and strengthen communication across the care team. Electronic platforms are needed
to share medical records and key information in an accessible format so that all team
members — including children and families — can communicate in real time, while respecting
Children and families should be confident that they are at the center of the team.
Shared decision-making skills are key to strengthening collaboration among team members,
physicians and families.
Communities need information and incentives to partner with pediatricians and others
dedicated to the health of children in a more comprehensive and collaborative team-based
approach to care. All stakeholders should examine how effectively they reach families
and children who need services and work together to close gaps in resources.
As the evidence mounts toward better understanding of the influences of social determinants
of health on outcomes, as well as the interdependence on mental and physical health,
it’s becoming increasingly apparent that pediatricians cannot do this work alone.
We are an integral part of, and uniquely qualified to serve as leaders of team-based
care, but we must look at the broader landscape to work with others to give children
and families what they need and deserve.
Dr. Kressly is a lead author of the policy and a member of the AAP Task Force on Pediatric