Psychosocial and Community Support to Address All Aspects of Care

Aurora partnership participates in nationwide “BUILD Health Challenge”

In 2017, a two-year grant brought together community organizations to create universal psychosocial, developmental and maternal wellbeing screenings to identify and respond to underlying needs in children before they experience negative long-term consequences.

Bold, upstream, integrated, local and data-driven (BUILD) Health Aurora was selected by a coalition of 12 funding organizations to participate in the BUILD Health Challenge, a national program that puts multi-sector community partnerships at the foundation of improving health for everyone. The Aurora-specific project focuses on creating and implementing group-based care models that are being piloted to serve women, infants and children (WIC) families at the Alton and Colfax WIC office in Aurora.  

“BUILD Health Aurora will expand access to early childhood mental health services for families with young children in community-based settings through screening, early identification and collaborative efforts to change systems of care,” said Dr. Ayelet Talmi, PhD, clinical director of the First 1,000 Days initiative at Children’s Hospital Colorado.

Collaborating to deliver community support programs and care

BUILD Health Aurora is a partnership among Assuring Better Child Health & Development (ABCD), Children’s Colorado and Tri-County Health Department. The partnership creates a continuum of early childhood mental health supports delivered in a local WIC office, primary care clinics and other community settings to address the upstream needs of families with young children and to enhance social emotional well-being.

Community health liaisons and early childhood mental health specialists collaborate to identify families in need of support and provide them with resources for prevention, health promotion and intervention. The partnership is focused on developing and implementing the necessary agency, community and systems-level changes to provide a continuum of comprehensive, high-quality care to young children and their families.

BUILD Health Aurora is one of 19 communities nationwide selected to participate. BUILD awards funding, capacity building support and access to a national peer learning network.

The program emphasizes cross-sector collaboration among local non-profit organizations, hospitals and public health departments to address upstream conditions that create opportunities for better health. BUILD selected BUILD Health Aurora because of its ideas to improve the health of its residents.

Community health liaisons embed support within communities

As part of the First 1,000 Days initiative, the Child Health Advocacy Institute launched its community health liaison program in 2016 with support from the BUILD Health Challenge. The program aims to address the many social determinants that keep kids from getting the healthcare they need.

As part of the program, community health liaisons meet families in their homes and in their communities, connect them with resources and help them with basic daily needs. Most of these families are immigrants, asylum-seekers or refugees, and some are homeless.

When community health liaisons Lah Say Wah and Denise Burd walked into a home that had a box of eggs in the freezer and a carton of milk on the floor, they were hardly surprised.

As community health liaisons at the WIC Clinic in Aurora, Lah Say and Denise see a wide variety of family dynamics and challenges that extend far beyond managing health. Many are recent refugees who don’t speak English and don’t know how to take a bus or where to shop for groceries, let alone how to use U.S. dollars to buy them.

“Culturally, it makes sense,” says Lah Say, who was a refugee herself. “Some families don’t know how to use canned goods or what a refrigerator is, but how could we expect them to when they’ve never owned one before?”

Lah Say came to the United States from Thailand with her parents and brothers in 2009. She spoke no English, yet knew she wanted to be involved with the Aurora community to help other families like hers. Now, she and Denise are two of eight community health liaisons at Children’s Colorado.

Addressing barriers to healthcare

In some cases, Lah Say and Denise work with a family for up to three months, helping them navigate public transportation, language barriers, food insecurity, Medicaid waivers and shopping for baby supplies. But they do much more than that. They create a nonjudgmental space, provide guidance and support, and serve as a lifeline to surviving in a new country.

“For me, it’s a way to pay it forward. When I first moved here, I barely spoke English, and I locked myself out of our home. This woman helped me and later brought cans of food to our apartment. I’ll never forget it,” reminisces Lah Say.

“For some families we serve, they don’t have food for the next day. They don’t know how to pay the bills. And when we come in and help them, it may take 10 visits to figure it out. But when we tell them, ‘We will help you get through this,’ we see hope.”

And when families feel hope, it’s the start of positively impacting their health outcomes.

Psychosocial health screening put into practice

“Do you have any concerns or problems that make it hard for you to keep your child's health appointments or manage your child's healthcare?”

Questions like these have become part of regular intake processes when families visit Children’s Colorado’s Child Health Clinic. We have an increased focus on screening families for issues like access to healthcare, resource needs like housing or food, financial challenges, safety, relationships and caregiver wellbeing.

The Child Health Clinic is one of the largest providers of pediatric primary care for Medicaid patients in Aurora, with children birth to five years old making up the highest patient volume. Here, the First 1,000 Days strategic plan provides a roadmap for the organization to enhance its impact in the early childhood arena through psychosocial screening efforts.

Understanding every family’s experience and challenges

“In the Child Health Clinic, we want to understand the circumstances that children and families face and the environments they live in when they come to us for their well-child and sick care,” says Dr. Talmi.

With this goal in mind and support from the Colorado Health Foundation, Rose Foundation and Caring for Colorado, the Child Health Clinic team launched a psychosocial screening initiative in 2016. This universal tool assesses all aspects of a family’s needs, environments and experiences, and connects them with appropriate resources.

The psychosocial screener asks questions about elements that are known to impact child health and a family’s ability to provide a safe, stable and nurturing environment for their child.

“Our clinic sees a diverse population of families from different cultures, languages, immigrant and refugee status as well as families that are largely publicly insured,” says Dr. Bridget Burnett, psychologist at Children’s Colorado.

“Our screener is available in 11 languages, meaning families can share issues related to housing or behavioral health that otherwise they may not know they can discuss with their doctor.”

Connecting families to community support programs and resources

When concerns are identified on the screener, a resource team member from family navigation, community health liaison, social work or integrated behavioral health helps address those needs.

“The medical training environment and screening provides a unique opportunity to embed population health management into pediatric training,” says Dr. Burnett. “When families receive access to resources and supports earlier, children receive the best opportunity for true prevention and health promotion.”

Dr. Talmi concludes, “When we understand, identify and address concerns and challenges related to environments and experiences, we are able to provide comprehensive healthcare and deliver the necessary services and supports to ensure that children are healthy, strong and thriving.”