Keeping Families Healthy (KFH) in Stony Brook, NY is a program that bridges the gap in pediatric care coordination by employing community health workers (CHWs) to serve as a liaison between families and their child’s clinicians. The program was founded by Susmita Pati, MD, MPH, to address challenges experienced by children and their families due to chronic or complex conditions, social risk factors such as lack of resources, language barriers, health literacy, transportation and insurance issues. Most recently, the program won the Academic Pediatric Association’s 2017 Health Care Delivery Award for “its innovation in linking the medical home with the community, engaging learners at multiple levels, and conducting academic work in concert with care delivery to at-risk children”.
Clinicians identify patients who are at risk for poor outcomes and refer them to the KFH program. Next, CHWs reach out offer to enroll families in the program. The role of the CHWs is to improve the family’s ability to receive necessary care and services, and work with them until both parties mutually agree the family is self-sufficient.
KFH has seven main goals: 1. Clarify how to seek appropriate medical treatment 2. Empower families to be prepared for appointments with clinicians 3. Facilitate families’ understanding of the clinician recommendations 4. Facilitate families creation of a system to keep track of their child’s medical information 5. Identify and address barriers to obtaining health care 6. Provide appropriate health education 7. Connect families with local community resources