Montefiore Medical Center

The first three years of a child’s life are the most crucial for long-term cognitive, physical, social, and emotional growth and development.

Children living in poverty begin life at a disadvantage, and may be deprived of what they need for healthy early development. Pediatric primary care practices can meet families where they are and with people they trust; 90% of all babies and toddlers regularly see a pediatric primary care provider. In many cases, though, pediatric primary care may lack the resources to identify families’ full social and emotional needs and to coordinate care for families. To address these needs, New York State has encouraged the expansion of the HealthySteps model, a national evidence-based approach to pediatric care coordination. In 2022, NYHealth awarded Montefiore Medical Center a grant to pilot HealthySteps in Bronx-based pediatric practices and test an alternative payment model to support its sustainability.

Under this grant, Montefiore will implement HealthySteps in community-based pediatric practices, restructuring well-child visits so a greater emphasis is placed on whole-child wellbeing and caregiver wellness. Universal screenings will assess both child needs and family needs. The model will screen all children using a tiered risk assessment, so children identified to be at highest risk will receive the appropriate level of intervention and coordination. Specialists will be trained by the national HealthySteps office to provide both in-person and telehealth support to families. Montefiore will also offer additional clinical training to providers, and staff will share best practices and strategies with community-based pediatricians. Finally, Montefiore will develop and test a payment model to support the sustainability of the program and establish a framework for statewide replication. Montefiore will share best practices, lessons learned, and strategies for successful implementation of the HealthySteps value-based payment model, with the goal of encouraging broad adoption by pediatric primary care practices and payers statewide.