Be Our Voice Blog

Monday, March 12th, 2012

Medical Home and Obesity: Connecting Patients to Community Resources

Posted by: Kristi Fossum Jones, MPH

In political and medical circles, the Medical Home is being called a critical part of the solution to our nation's healthcare system. While the term “medical home” may be newly in vogue, the idea of the medical home is nothing new, especially in pediatrics: the AAP started talking about medical homes in 19671. The current definition highlights the unique situation and needs of children: the medical home is a model of patient and family-centered, community-based care that provides continuity of care from childhood through adolescence and facilitates a smooth transition to adult services.2 Implementing the pediatric medical home model is an ongoing focus for NICHQ and other pediatric care organizations in order to achieve higher quality care for kids.

One component of the medical home that is particularly important for childhood obesity is the community-based system:  a patient and family-centered coordinated network of community-based services designed to promote the healthy development and well being of children and their families.3 “Community-based” means services are available in the communities where children and families live, work, learn, and play—not just within the walls of the doctor’s office or hospital. A community-based system with nutrition and exercise programs to support children and families can help to combat and prevent childhood obesity.

Communities everywhere offer a plethora of potentially helpful obesity-related services and programs, ranging from YMCA sports to community gardens, but families may not know these exist and may not know how to access them. The most at-risk families are often the most isolated due to poverty, language barriers, lack of transportation, etc. When children are too young for school, their families lack the community connections that would be facilitated via the school system. 

For some families, the pediatric provider may be their only reliable, regular source of information about child growth and development—and about community resources—until their child starts kindergarten. This is unfortunate because most parents need, and want, good information. Yet it makes a strong case for the unique position healthcare professionals hold as both medical caregivers and providers of  practical information. Indeed, “parents expect their doctor’s office and the health clinic to be a place where they can get reliable community resource information4.” Thus, healthcare professionals working within a medical home are crucial links in the chain between families and community resources.

How can healthcare professionals best connect families to resources? There are several ways.

First, connecting families and community programs can, and should, take place in a clinical setting. Waiting rooms and exam rooms are ideal places for brochure racks that house brochures about local nutrition and exercise programs, written in the languages of the patient population. Pediatric providers could use something like the AAP’s Healthy Active Living Prescription to give families information about community health resources—during a checkup, a pediatrician could write the phone number of the local YMCA on a prescription and give it to a parent. Some practices may already have staff or volunteers onsite whose express role is to help patients access community resources (e.g. Health Leads, Community Health Workers, etc.).

Second, when existing policies are hindering or even preventing efforts to address the causes of childhood obesity, healthcare professionals can use their unique and powerful position to advocate for sustainable changes in their communities. For example, a school nurse could go to the local school board to propose changes to the district’s nutrition policies and provide examples of patient stories that support such changes. NICHQ’s Be Our Voice project trains healthcare professionals in advocacy by providing a curriculum, toolkit, and technical assistance resources for those who wish to become advocates for policy changes that positively impact childhood obesity outside the clinic walls.

Third, if there are insufficient community resources to which families can be referred, healthcare providers can form partnerships or join coalitions to create community programs and services for their patients. This kind of work is happening in NICHQ’s Collaborate for Healthy Weight initiative, in which teams of primary care providers, public health professionals, and community organizations address obesity at the community level. Part of the project is coming up with long-term ways to promote nutrition and exercise plans in communities, which may involve developing new partnerships and new resources. Another example of creating resources is the program Walk With a Doc, in which healthcare providers lead community walks for patients and families to offer healthy exercise options. 

Fourth, healthcare professionals can practice both clinical and community advocacy by joining with external organizations to offer resources onsite. In some places, to meet the needs of those at highest risk, such “one-stop shops” offer medical care and more. For example, the Hennepin County Medical Center Pediatric Clinic in Minnesota has instituted a hospital-based food pantry where food is given to needy patients and families when they come for office visits. This strategy both helps to prevent hunger and, since the food meets clinical nutrition standards, helps address some of the possible causes of obesity.5 On a national level, Kaiser Permanente’s prevention efforts include teaming with local organizations near their medical centers to offer Farmers’ Markets onsite, which increases access to fresh produce for patients, families, and staff.6

Medical homes offer the opportunity for children and families to receive comprehensive, coordinated medical care—and, as part of this, to be connected to community resources that can help them lead healthier, more productive lives. Making these connections is a vital part of addressing and preventing childhood obesity, and it benefits patients, families, and healthcare professionals alike.      


1. National Center for Medical Home Implementation. “History of Medical Home at the AAP.”                       
2. National Initiative for Children’s Healthcare Quality. “Area of Focus: Medical Home.”
3. National Center for Medical Home Implementation. “Family-Centered Medical Home Overview.”
4. Palfrey, Judith. Child Health in America: Making a Difference Through Advocacy. Baltimore: The Johns Hopkins University Press, 2006. Page 107.
5. Barr, Sarah. “Where 'Hospital Food' Takes On A New Meaning.” Kaiser Health News. November 22, 2011.
6. Kaiser Permanente. “Medical Center and…Grocery Store?”   

Healthy Kids  General Childhood Obesity 


No comments have been added.

(required, but never shown publicly)