Initiatives

PARTNERS created a family center model for comprehensive primary care at for the Hughes Spalding Primary Care Clinic at Children’s Healthcare of Atlanta. We have continued to provide comprehensive family support services for the many children who consider our center to be their medical home. Such support includes a two-generation approach to providing screening and services for children and their families.  

Faculty, residents, and staff are trained in the rationale and use of screening tools for the patients and their families. Specifically, PARTNERS support has allowed for the creation and implementation of screening tools for the family, child, and adolescents; support for a behavioral health coordinator; and support for a comprehensive family case management program called PACE, which stands for pediatric access, comprehensive family support, and education. 

The process for patient and family behavioral health support includes: 

• Screenings for social determinants of health through a family resource survey, which is administered with each well-child visit. This assessment identifies determinants such as housing insecurity, food insecurity, unsafe housing/community conditions, exposure to interpersonal violence, for example. We paired this assessment with an accompanying guide to hospital and community resources to address each problem identified during the screening. We also screen for Adverse Childhood Experiences (ACEs) for both parents and young children. We continue to update both the universal screening process and the approach intervention. Our goal is to address these issues in a manner that best assists families to receive education, counseling, or other services as significant history of exposure to trauma and adversity is identified. 

• Developmental screening during well visits for children between six months and five years of age. 

• Psychosocial risk-screening questionnaires for children between five and ten years of age and for adolescents, addressing the home, education, eating, activities, drugs, sexuality, suicide/depression (HEADSS) survey for adolescents. 

Through these screenings, we have been highly successful in identifying behavioral health needs of our patients and their families. In recent years, Children’s Healthcare of Atlanta has embraced the delivery of integrated behavioral health services based on the model created by PARTNERS some 5 years ago. We are excited to see this level of investment in the mental and behavioral health of our children and families. This level of support allows us to focus on the whole child within the context of their family and community. 

The Center for Family Resilience (CFR) was created in response to the growing mental health crisis in our country, with 1 in 5 children experiencing mental and behavioral health disorders. These issues affect a child's well-being, their ability to achieve academic goals, and their long-term ability to become a functioning member of society.

While seeing patients in our primary care medical home, we recognized the urgent need to support the relationships between parents and young children that were often harmed by the trauma that parents, children or both experienced. While our clinicians recognized these difficulties, they did not have the training and capacity to fully address them. Further, there were very few mental/behavioral health services that focused on young children. Hence, the Center for Family Resilience was created as a service where parents and their children could receive trauma-based therapeutics in an effort to help heal the relationships. After receiving a full evaluation by the Families First team and the child psychologist, eligible families receive an appropriate therapy such as Child-Parent Psychotherapy (CPP) or Parent-Child Interaction Therapy (PCIT). 

The Center for Family Resilience (CFR) has made significant strides in supporting families through comprehensive programs and partnerships. The center is located within a Families First service site, which is staffed by child and family therapists, a psychologist, social workers, child and adult psychiatrists, peer support/community liaison staff, and a coordinator. Referrals can be made by pediatricians and residents from the Hughes Spalding Primary Care Clinic. We are pleased to report that since our first family was served in August 2023, we have provided comprehensive services to thirty-four families. These services begin with the initial referral from outside practices or agencies and continue through intake by the Families First staff where a comprehensive family assessment is completed, evaluation by our psychologist to determine the best disposition for the family, and initiation of dyadic therapy. Our families have often experienced severe trauma which has contributed to the breakdown of the parent-child relationship.  

CPP Participant feedback:

“CPP is helping me learning as a parent and a person that it’s a little difficult to be a parent as well as to understand how to effectively communicate with him without getting upset myself. I didn’t like having to speak on my previous trauma, especially the ones as an adult, but it felt good having someone there to actually listen to me. Overall, my thoughts on the program are that it can have a positive impact on my family. I know that there are a lot of things I need to work on as a mother and human being. I look forward to the hands-on activities that Dr K will do with me and my son. The program has been good so far and I look forward to completing it and providing more feedback in the future.” 

PACE is a monthly, multi-disciplinary care team meeting designed to provide comprehensive support to families and patients with medical and/or socioeconomic complexities. By leveraging a multi-disciplinary care team approach, PACE aims to help these families’ overcome obstacles and barriers that hinder the fulfillment of their child's social and healthcare needs.  

The team includes primary care physicians, nurse navigators, medical social worker, a behavioral health consultant, a HeLP public interest attorney, a chaplain, and a nurse case manager. Residents are also invited to participate. The care team reviews and case-manages families and patients who need assistance in overcoming barriers to meet their child’s social and healthcare needs. The primary goal of PACE is to empower families to take ownership of their child's care. PACE is dedicated to assisting all families requiring multi-disciplinary support. 

PACE is committed to addressing the complex needs of families by providing a collaborative and supportive environment tailored to each family's unique circumstances. 

PARTNERS is dedicated to providing pediatric residents with holistic training that is socially conscious and produces pediatricians who are dedicated to whole-child care and addressing social determinants of health.

In the last year, we have trained 54 residents to provide family-centered care in the primary care clinic at Hughes Spalding. We have held advocacy-focused training for all 89 of our residents to prepare them to be lifelong pediatrician-advocates for their patients. Our faculty oversees their community rotation, which exposes them to community-based agencies that support child health, including school-based health services, nonprofit organizations, food banks, our health law partnership, and many more.

We also meet with residents weekly for structured discussions around topics such as advocacy, social justice, food insecurity, and trauma-informed care. We have successfully launched a specialized advocacy track (PEACHES) for residents that includes experiential learning sessions and skill-building, structured didactics, and a mentored longitudinal project for each track participant. With mentorship from our faculty, our track residents attend both the AAP’s national advocacy conference as well as the Georgia AAP’s day at the capitol, where they can put their advocacy skills to use.  

"Whatever specialty I may choose whatever career path I may follow, I know that everything I have seen and heard and read during this rotation will stick with me. I know that I will do my best to be an advocate for my patients and to work with them one-on-one to meet them where they are really at, to make sure the social determinants of health are in place for them"  

As a demonstration of its commitment to training pediatricians to address the most pressing issues facing children, the Emory Department of Pediatrics launched the PEACHES residency training track in 2022. PEACHES- Pediatric Equity, Advocacy, Community Health, Environmental and Social Justice-trains pediatric residents to become informed clinicians, leaders in their specialty and community, and advocates for children and families.

The program onboards a new cohort of second-year residents each year and provides them with a 24-month curriculum, opportunities to gain experience advocacy skills on the institutional, regional, and national level, and exposure to community-based organizations that focus on child and family health outcomes.

During their time in the track, participants learn about the significant non-medical drivers that shape child health outcomes, such as poverty, discrimination, food, and housing insecurity, as well as the exposures that also shape health outcomes. These include contaminated water, soil, and air, as well as exposure to adversity during the early childhood years.  

Reach Out and Read partners with clinicians and uses the pediatric well-child visit to support parents and caregivers in using shared reading to build early literacy skills and healthy relationships with their young children. Our practice at Children’s Healthcare of Atlanta at Hughes Spalding was the first program in Georgia to adopt Reach Out and Read in 1996. Since that time, we have given our families age-appropriate and culturally relevant books and discussed the importance of shared reading at each well-child visit.

Over the years, our practice has distributed more than 235,000 books, along with advice for parents about incorporating shared reading into their daily routines. Because we are an academic practice, in addition to serving as a medical home, we also train pediatric residents and medical students. As a result, our reach has been amplified. All trainees who come through our practice are steeped in the brain science and delivery approaches that are a part of Reach Out and Read.

Research shows that the presence of books in the home is a strong predictor of reading achievement, and low-income families have fewer books in their homes compared to wealthier children. Reach Out and Read targets under-resourced communities to reduce this gap. Eighty percent of a child’s brain develops in the first 1,000 days of life. Reading aloud with children teaches them how to listen, builds early language and literacy skills, and helps them learn about the world. It also teaches them to be curious, empathetic, and patient.

At the well-child visit, we can use a book to evaluate the child and look for developmental milestones. In addition to encouraging parents to read with their children daily, we work with them to be more engaged while reading. Reading aloud helps create and strengthen bonds between the parent and their child. It is proven that healthy relationships are key to social, emotional, and mental development as they get older. 

We are also intentional about ensuring that our families and children see themselves and their communities reflected in the books we provide. Our team has been one of the most ardent supporters of Reach Out and Read in our site, community, and beyond. Our team also supports this important initiative more globally as Dr McFadden serves as Medical Director for Reach Out and Read Georgia and sits on the Board of Directors for the national organization.  

Promoting Resilience, Educational Achievement, Citizenship, and Hope
A School-based Health Center-led Violence Prevention Program  

The school-to-prison pipeline is a disturbing national problem where children are systematically siphoned out of schools into the prison system. Students of color (our primary focus) receive disproportionately harsher disciplinary actions, which increases the risk of entering the juvenile justice system.

Project R.E.A.C.H. seeks to address the root causes of disruptive behaviors and decrease exclusionary discipline practices in schools by understanding student mental health, collaborating with school staff, and developing targeted resources to create a favorable school climate. Project R.E.A.C.H. leverages School Based Health Centers (SBHCs) mental health services to proactively identify and mitigate risk factors contributing to student disciplinary referrals.

By offering R.E.A.C.H within the SBHC setting, we hope to decrease the barriers and stigma associated with mental health care. This also increases parent and student engagement by integrating mental healthcare into the total care of the student. This allows for earlier screening and identification of mental health needs and addresses needs more effectively and holistically.  

Currently, Project REACH is being piloted at 2 Georgia middle schools, KIPP Vision Primary School in Atlanta and Albany Middle School in Albany. After extensive planning, the program successfully started serving 6th- 8th graders at these 2 schools in January 2025. 

Key project activities include: 

• School Counselor Interviews: Gathering insights into available mental health resources and strategies for managing challenging behaviors. 

• School Staff Surveys: Understanding perspectives on students exposed to trauma and its impact on their behavior, as well as identifying stressors affecting staff wellness. 

• Trauma-Informed Care Training: Offering training by members of Emory’s School of Public Health in equipping school staff with essential skills in self-care as well as management of challenging student behaviors. 

• Student Surveys: Assessing student challenges and their impact on behavior and academic performance. 

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS): Structured weekly sessions with students led by SBHCs mental health provider. 

• Leadership Development: Partnering with our colleagues at Emory’s School of Theology to develop a curriculum to implement with CBITS. 

At the end of the two-year project period, we will evaluate the program by surveying students and staff and analyzing school attendance and disciplinary data 

The Georgia School Based Health Alliance (GASBHA) received the Hallways to Health grant from Kaiser Permanente Thriving Schools Program in the Spring 2013. Three school-based health centers (SBHCs) were selected to participate in the Hallways to Health Program:

• Whitefoord Elementary located in southeast Atlanta
• Lake Forest Elementary located in Sandy Springs
• Turner Elementary located in Albany

Hallways to Health is a collaborative that aims to improve the well-being of students, their families, and school staff by guiding school-based health centers (SBHC) to facilitate programs and policies to prevent and reduce obesity, and address social and emotional health issues. During year one, SBHC staff at the three centers were directed through a process to improve their clinical practices so that they are able to provide the highest-quality of care related to obesity prevention and social and emotional health. They learned how to integrate and increase their involvement in existing or new health promotion efforts in the school and broader community in the areas of physical activity, nutrition, and wellness. The SBHC staff were trained to work in collaboration with students, teachers, and school staff to create an environment where nutrition and wellness programs and activities are available to everyone in the school and positive health messages are reinforced. SBHC staff are able to refer and link students to appropriate treatment options that may be available in the community.

During the first two years of the Hallways to Health initiative, the SBHCs accomplished amazing success implementing staff wellness programs and activities in their respective schools (Biggest Loser Competition, Adult Health Month, Flu Vaccinations, Walking Program, Staff 5K Walk/Run, and Blood Pressure Screening). The SBHCs also implemented obesity prevention interventions to address the needs of students (Youth Wellness Program/Kool Kids, Wellness and Fitness Programs, small group healthy eating and physical activity intervention, and involvement in the Georgia Fitness Assessment activities). The SBHCs addressed social and emotional health issues and counseling within the student population. The SBHCs also promoted parental and caregiver engagement by providing health education information and services related to healthy eating, physical activity, obesity prevention, and addressing their children’s behavioral health issues.

The Georgia SBHCs highlighted their year one, year two successes, and year 3 successes and policy or system change accomplishments at the 2014 National Hallways to Health Midpoint Meeting in Seattle, WA (year one), the 2015 National Hallways to Health Endpoint Meeting in Austin, TX (year two), and the 2016 National Hallways to Health Midpoint Meeting in Arlington, VA (year three) respectfully, presenting their storyboard presentations and panel discussions to tell “A year in the life of our SBHC/Hallways to Health Program” and “Policy/Systems change as a result of the Hallways to Health Program”. Presenters from other states participating in the Hallways to Health initiative include Washington State/Oregon, Maryland, and California. Participants received training from School-Based Health Alliance, and Kaiser Permanente Thriving Schools staff.

Each of the five states and 13 sites participating in the initiative received an additional two-years of funding for the 2015-2017 academic school years to continue Hallways to Health (now known as Hallways to Health Phase 2, or H2H 2.0). Hallways to Health Phase 2 continues to focus on the three aims of the program (healthy eating/physical activity, social and emotional health, and school employee wellness). Furthermore, Phase 2 of the program consists of strategically planned population health and public health training courses and technical assistance led by American Public Health Association (APHA) in partnership with the School-Based Health Alliance and Kaiser Permanente Thriving Schools Program, conducting a school-wide needs assessment, environmental scan, focus group discussions with students and parents, evaluation and reporting of program outcomes and impact, and continued learning collaborative activities. Year four of the program will focus on the continuation of school employee wellness efforts, implementation of the student health wellness plans, and development of sustainability plans.

Each of the three Georgia H2H grantees successfully administer the H2H staff wellness survey in year three to assess the needs of staff in their respective schools and developed their school staff wellness action plans for implementation during the 2015-2016 and 2016-2017 academic calendars. Staff wellness activities include continuation of the Biggest Loser Competition, Walking Programs, and access to healthier food options in the school cafeteria for school staff. Additional activities for school staff wellness include access to water coolers in the teachers’ lounge areas, access to Farmers Market during school hours (to accept EBT), meditation and stress management opportunities offered to school staff during school-wide testing periods, yoga, and wellness room available to school staff, as well as the development of a walking track, and providing pedometers for school staff to track steps for walking programs.

H2H grantees successfully implemented the Rapid Assessment for Adolescent Prevention Services (RAAPS), a school-wide needs assessment (for upper elementary school students in 4th and 5th grades) and developed their student wellness action plans based on the results of the needs assessment with TA and training provided by APHA and the state affiliate from GA, as well as the feedback provided by students and parents during their focus group discussions. Implementation of the student wellness action plans will begin during the 2016-2017 academic school year for elementary school students and have a school-wide focus to address the needs of students in the area of healthy eating/active living and social and emotional health.

2014 Hallways to Health Midpoint Meeting participants (from California, Georgia, Maryland, Washington,
Oregon, SBHA staff and Kaiser Permanente Thriving Schools staff)

  
Turner Elementary SBHC Provider and H2H Health Educator, Sara Trivette presenting
at the 2016 H2H Midpoint Meeting

  
Lake Forest Elementary SBHC H2H Health Educator, Kathleen Malcolm presenting
at the 2016 H2H Midpoint Meeting

  
Whitefoord Elementary SBHC H2H Health Educator, Tocee Harmon presenting
at the 2016 H2H Midpoint Meeting