Parent-Infant Dyad Community Resource Mapping

Building a Strength-based Holistic Mapping of the Family

Mapping community resources involves multiple layers of clinical/medical, psychological, financial, and social information. It is important that the clinical care plans and mapping are individualized to meet families where they are in their recovery journey, consider family members roles, and their priorities. The necessary data is collected from birth parents, foster/kinship caregivers, friends, and family members.

Community resource mapping identifies and facilitates connection to both, pediatric and adult medical specialists, and subspecialists (ie, ophthalmologists, infectious disease, obstetrician-gynecologists, dentists, etc.) The mapping process also identifies community partners and financial services, such as Early Intervention (EI) Women, Children, and Infants (WIC), mental health services, OUD and addiction recovery services, legal counsel, home visiting, food security, housing and, domestic violence shelters.

During the initial assessment and all subsequent health supervision visits, pediatricians can use empathetic interpersonal communication approaches to collect the information that guides the mapping process. Through open-ended questions, pediatricians can identify significant family members, support people, learn about the family structure, and understand the nature and dynamics of relationships among family members. These conversations are essential to understanding the gaps in health services, financial status, health goals, family communication tools, unmet needs, and other family stressors that may affect the health and safety of the dyad.

Sample open-ended questions and prompts to gather information for community resource mapping.

• Tell us about who lives in the household.
• Are there any family members or friends living in the household or nearby that can help, or be there for you if you need them?
• Who helps with childcare?
• Has there been a referral to Child Protective Services (CPS), or is there an open case with them?
• Tell us about your healthcare plan.
• Do you have any financial concerns?
• What types of services do you or other family members receive? Are they easily accessible?
• Are there other services that you feel you need for yourself, or infant/child?
• Do you ever worry about running out of money at the end of the month?

Continuous Connectivity to Resources

Each pediatric health supervision visit is an opportunity to offer anticipatory guidance to families about the importance of developmental surveillance and screening for all infants and children exposed to opioids prenatally. Pediatricians can discuss parental observations of the infant and home, conduct appropriate screenings, and make referrals to EI services as necessary.

Continuous transparent communication between the care team and family members can bring consensus and resolution to any changes and updates to the medical care plan. With a focus on the family strengths, pediatricians can engage in dialogue to assess potential shifts in the need for informal and formal community support services and consider new and additional referrals.

Forging therapeutic alliances and providing emotional support are essential strategies for building strength-based holistic mapping for parent-infant dyads affected by OUD. Pediatricians can facilitate connections and warm handoffs to recovery and addiction treatment services. Peer recovery coaches and other members of the clinical teams can serve as, or assign advocates to work with families in recovery and provide continuous support during their recovery journey.

Care Coordination and Linkage to Community Partners and Resources

A care coordinator or other team member taking on this role, can be an essential point of contact during the initial parent-infant assessment and during all follow-up visits. The coordinator role can have various non-clinical responsibilities such as, assisting with intake screening, planning the care, assisting with transitions, and streamlining documentation. Coordinators can link families to community supports, guide them in accessing insurance and financial assistance for health services, optimize insurance coverage, and train families and other staff in record keeping and/or navigating the care systems. Care coordinators can also develop ad-hoc hand-written handouts for families, to detail all available community resources.

When a care coordinator is not available, practices can explore connecting families to a trained parent consultant, who can perform many of these responsibilities. People in recovery are more inclined to trust someone with a similar experience, same race, ethnicity, or background. As a result, a person in recovery will be more likely to access a service or show up for an appointment if the recommendation comes from someone they trust. Important to remember is that family members, friends, and peers in recovery can offer trusted support to a parent in recovery.

Having the duties of care coordination assigned appropriately, allows clinical and medical staff to steer their attention to providing medical recommendations, treatments, and referrals to specialty and subspecialty care for the dyad.

• Developmental screening and surveillance
• Pediatric infectious disease and ophthalmology specialists
• Adult reproductive care and/or family physician
• Addiction specialist and/or provider for medication treatment for opioid use disorder
• Substance use and addiction recovery programs and peer support groups.

Community Resource Mapping Benefits

• Child and family-centered approach
• Plan of safe care implementation
• Timely connection of parent-infant/child dyad to necessary services and resources
• Parent-infant dyad stays together
• Early Intervention monitoring
• Differentiated, individualized, and comprehensive care
• Continuously revised health goals and care plans
• Pediatrician and family collaboration
• Increased proactive care than reactive care
• Families empowered to seek community resources
• Improved clinical and health outcomes
• Enhanced pediatric partnerships with community local resources.

A sample community resource map demonstrates formal and informal supports that can be coordinated through the pediatric medical home for mother-infant/child dyad, interventional care, and community-based support services.

Pediatric Medical Care & Community Services

• Developmental surveillance Pediatric infectious diseases
• Specialist
• Ophthalmologist
• Early Intervention (EI)
• Neurologist
• Pediatric palliative care.

Childcare & Education

• Pre & after school care
• Early Head Start
• Head Start
• Speech & language therapy.

Adult Medical Care & Community Services

• Adult primary and reproductive care 
• Infectious diseases specialist
• Dentist
• MOUD provider
• Mental & behavioral health
• Addiction specialist
• Substance use & addiction recovery services
• Support groups, peers, coaches.

Financial Supports

• Medical insurance
• Respite Care
• Childcare subsidy
• Social security
• Food subsidy
• WIC & SNAP
• Parenting & professional training
• Employment
• Legal counsel.

Dyad community services

• Home visiting
• Domestic violence shelter
• Nutritional counseling
• Child protection services
• Parenting resources
• Transportation.

Informal Supports

• Personal care services
• Extended family & friends
• Social, cultural & faith-based groups
• Recreation & sports clubs.

Additional Resources

• Community Tool Box – Geographic Information Systems: Tools for Community Mapping – Tools, resources and examples of community maps that can be utilized by child health professionals.
• Family to Family Support Network – National network for finding a trained parent and connecting families with and connecting families with parenting and community resources.
• 211.org – National call line offering live assistance with needs such as, food, counseling, income supports, employment, healthcare, and other services for specialized populations such as the elderly and persons with disabilities and much more.
• AAP Medical Home – National technical assistance center focused on improving the health and well-being of children and youth with special health care needs and their families.
• Integrated Care at Boston Children’s Hospital: Care Mapping – Downloadable practical guides for families and professionals.
• Community Action Partnerships (CAP) – National tool for finding agencies that can help with local community services such as, rent assistance, food pantry, etc.
• Linking Systems of Care for Children and Youth – Materials for building a directory of resources on mapping community assets.