​Supported in part by a Healthy Tomorrows Partnership for Children Program grant awarded to the East Tennessee State University Department of Pediatrics, this project engages a multi-disciplinary team of students and professionals to coordinate care for families and children. The project has shown improvements in breastfeeding sustainment, injury prevention, decreased screentime, and improved nutrition among children, youth, and families.
Implementation Insights:
  • Use social media to engage families in health care and community initiatives.
  • Develop innovative, family-friendly resources to promote implementation of Bright Futures guidelines within the context of a pediatric medical home.
  • Implement multi-pronged communication strategies to foster and sustain team-based care.

Updated: September 2016

 Background Information

  • Type of Practice: Academic Institution
  • Location: Johnson City, Tennessee
  • Population Served: Over 2,000 families are served by this project throughout the year. Approximately 85% of the patients and families served are publicly insured.

 Pediatric Medical Home Implementation Strategies

  • Form a multidisciplinary community advisory board to advise the development, implementation, and evaluation of the project. Advisory board members may include the following:
      • Title V program staff
      • Families and community members
      • Clinicians
      • Representatives from the local department of health
      • Representatives from the state chapter of the American Academy of Pediatrics
      • Other health professionals
  • Apply the Theory of Planned Behavior, which focuses on facilitating positive perceptions of healthy behaviors as social norms, to guide the development of a model for improving family education, engagement, and child health outcomes.
  • Integrate pediatric residents and psychology, social work, and medical students into the clinic to implement a team-based, coordinated approach to the provision of health care for families and children.
  • Communicate Bright Futures recommendations to the community through the development and use of innovative, family-friendly resources.
      • Create "My Baby Book," a physical book which contains age-appropriate tips for keeping babies healthy and safe during the first two years of life based on Bright Futures guidelines, as well as space to record special memories and milestones, and plan parent-child activities. Create the book at a 6th grade reading level to enhance accessibility for all families.
      • Give families "My Baby Book" at their newborn visit; ask families to review the book and fill the book with information specific to their family and child.
      • Encourage families to bring "My Baby Book" to each subsequent clinic visit to share and discuss with their provider, thereby enhancing comprehensive, coordinated, and family-centered care. 
      • Create a "Healthy Active Living Tips" booklet that provides suggestions for activities to keep the entire family healthy.
      • Create wall posters and children's books (for children ages 3-5 years) with developmentally appropriate tips for safety, healthy eating, and active living to distribute as part of Reach Out and Read.
      • Create Spanish and English versions of all family resources.
      • Provide training and support to clinicians so they can advise families on how to utilize "My Baby Book," the "Healthy Active Living Tips" booklet, and children's books created for children ages 3-5 years.
      • Create free mobile application based on print materials to expand access to “My Baby Book” and ‘Healthy Active Living Tips.”
  • Use social media to engage and connect families with opportunities for support, health education, and community initiatives that promote healthy living.
      • Host support groups and community events for families and caregivers
      • Explore multiple strategies to obtain family feedback on program components and priorities, including the following:
      • Create and disseminate family surveys that collect data on maternal and infant behaviors of interest (including breastfeeding, fruit and vegetable consumption, book sharing, screen time, injuries, and active lifestyles).
      • Conduct follow-up interviews (via telephone) with families to obtain further information and feedback on the ReadNPlay program.
      • Disseminate periodic anonymous surveys during community events.
      • Collect family stories from Mommy and Me support groups and other peer support meetings.


  • ​Communication between faculty, residents, students, other interprofessional colleagues, and community partners as well as families has been the project's biggest challenge. To address this challenge, the project utilized a multi-pronged communication approach including the following:
      • Frequent meetings
      • Emails
      • Posters
      • Flyers
      • Social media
  • Financial sustainbility beyond grant funding remains an ongoing challenge. Staff and leadership continuously explore additional grant funding opportunities.

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