Young children and their families benefit from aligned health and social supports and services to promote healthy development, meet their health-related social needs (HRSN), and foster nurturing relationships with caregivers. Yet, many early childhood and family-facing agencies providing health and social services work in siloes, despite serving the same families. These siloes often create difficulties for the families navigating them, especially families with complex health and social needs.

Alignment across Medicaid and early childhood systems can break down siloes and better serve children and families by streamlining processes that can be frustrating and confusing; reducing duplication of services and ensuring efficient resource use; improving connections between programs and services along the continuum of care; and leveraging resources, including funding streams, for new programs to address unmet needs. However, alignment of early childhood and Medicaid systems should not happen in a vacuum. By engaging families and other impacted stakeholders in cross-sector alignment efforts, policymakers can get to the root of what matters most to families, and better understand what works well and where gaps and challenges exist. When families and providers are included in policy design and decision-making processes, programs and systems become more family-centered and responsive to the needs of children and their families. This brief outlines four key strategies to engage families and providers in co-creating cross-sector alignment solutions that can more effectively serve children and their families. It draws from the experiences of state participants in Aligning Early Childhood and Medicaid: Maximizing the Impact of Federal Funding Opportunities, a national initiative led by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation. The initiative convened cross-agency teams in Alaska, Illinois, Nevada, North Dakota, and Oklahoma to explore opportunities to improve alignment of Medicaid and early childhood services. The teams, composed of Medicaid and early childhood-facing agency staff, worked with community partners to engage families with young children and providers to inform alignment efforts.

Strategies for Engaging Families and Providers in Aligning Medicaid and Early Childhood Services

It is important to engage individuals, families, and providers at the onset of alignment efforts and throughout the process. Families can share their lived expertise to spotlight pain points and elevate community-driven solutions to improve systems. Providers bring in their own expertise in how systems are currently working and where gaps and opportunities exist. Following are four strategies states can use to center and effectively engage families and providers when working on systems alignment.

1. Partner with Community Organizations Who Can Effectively Recruit Families and Other Stakeholders

Understanding families’ experiences navigating state programs and services, like Medicaid and early childhood programs, is essential to improving them. Families can help identify strengths and opportunities for improvement in the programs they interact with, which can focus and prioritize state efforts. To reach families where they are — in their own communities — state agencies can partner with community organizations that have existing relationships with parents and/or community leaders.

As part of its efforts to listen to families early on, the Illinois team, which included Medicaid and the Department of Public Health, worked with two community partners who could recruit, compensate, and engage families effectively: Community Organizing and Family Issues, an organization focused on building the leadership skills and voices of parents to inform policy decision-making, and Brightpoint, a provider of family and early childhood services for underserved communities. These partners recruited for and conducted listening sessions and individual interviews with pregnant or parenting individuals, including individuals from Black communities and Spanish-speaking, immigrant communities across the state. The goal was to better understand how access to pre-natal and postpartum services, including doula services, could be improved for families. By listening to families, the state team learned that many had difficulties getting the information they needed to access care and services during and after pregnancy. Families offered suggestions to improve communication about available services, including a need for more translators due to a limited number of Spanish-speaking providers, clearer information on what services are covered for Medicaid beneficiaries without paying out‑of-pocket, and more peer-to-peer supports. These suggestions both re-affirmed priority areas for state improvement efforts and highlighted additional ways to better support children and families.

Providers who deliver services to children and their families can also shed light on alignment hurdles and opportunities. The Oklahoma cross-agency team, which included Medicaid and the Department of Mental Health and Substance Abuse Services staff, partnered with the Oklahoma Association for Infant Mental Health (OK-AIMH) — a statewide professional association serving a diverse workforce focused on infant and early childhood mental health — to conduct a provider survey using their extensive member database. Through the survey, the state was able to identify policy, administrative, and coverage hurdles providers face when conducting early childhood mental health assessments, making a diagnosis, and providing appropriate treatment options.

2. Work with Trusted Community Partners to Engage Families Authentically

States can work with community partners to authentically engage families or providers. Working with community partners who are trusted by the communities they serve is important when engaging in authentic and sometimes difficult conversations. Community partners ideally understand the cultural norms of the communities they work with and have the skills to engage families most impacted by structural racism and with high unmet needs. For example, in facilitated conversations, it is important to provide space for reflection so that parents feel comfortable sharing. These conversations can also serve as an opportunity for parents to connect with one another, share their experiences and resources, and offer peer support.

The Alaska team, which included Medicaid, the Division of Public Health, Division of Behavioral Health, and the Office of Children’s Services, partnered with Rural Alaska Community Action Program (RurAL CAP), a community organization that delivers early childhood and maternal programs to underserved rural communities across the state. RurAL CAP leveraged its trust with the rural communities it has served for nearly 60 years and its extensive geographic reach to recruit providers and families to participate in journey mapping activities  based on a human-centered design approach.

Alaska’s journey mapping process convened three audiences — state agency staff, providers, and families —  to better understand how pregnant people impacted by substance use disorder (SUD) experience systems they come in contact with and access needed services during pregnancy. Having three distinct perspectives provided an overview of how the systems in place “should” work together to provide services for families from the policymaker perspective, how they “actually” work from the provider viewpoint, and how they are “experienced” by families. This process provided valuable information to the state as it combined the experiences of all three stakeholders and identified tensions between the ideal system versus the reality. By partnering with RurAL CAP, the Alaska team benefited from the expertise of providers and families who have accessed services. With this understanding, the state was able to identify pain points and opportunities for improvement, such as using existing services like MyAlaska, a state-wide virtual platform that allows individuals to interact with multiple Alaskan state agencies, to support access to services and care coordination.

When selecting community-based organizations with whom to partner, states can consider the stakeholders they want to engage and what type of information they are looking for so that they can lean into partnerships with organizations with expertise in that space. The Nevada team, including Medicaid and the Division of Public and Behavioral Health, Child, Family, and Community Wellness staff, sought to hear from families about their understanding of and experience with home-visiting services. To do this, they worked with the Children’s Advocacy Alliance, a statewide child well-being advocacy organization, which recruited two on-the-ground partners to contribute unique expertise and relationships with different populations: The Obodo Collective, an organization that provides supports to families including resources for food, employment, and housing, and the Heart and Sol Collective, an organization that provides doula services, prenatal classes, mental health services, and support groups. The Heart and Sol Collective facilitated conversations with current or recently pregnant individuals while the Obodo Collective engaged families with school-aged children. The two groups provided unique perspectives that helped the state better understand how families use home-visiting services and identify ways to increase families’ awareness of available programs.

3. Engage with Cultural and Linguistic Awareness and a Trauma-Informed Lens

When it comes to engaging families, words matter. Things can get confusing or lost in translation when families mistrust state agencies, have low health literacy, or when English is not their first language. It is important for questions to be asked in a clear, open-ended, respectful, and strength-based manner. Having engagement facilitators who are culturally and linguistically competent as well as limiting who else is in the room during family engagement sessions are both important considerations to reduce power imbalances and foster trust and authentic conversations with families. Many of the state teams participating in CHCS’ Aligning Early Childhood and Medicaid initiative worked with Family Voices — a national organization focused on empowering families to advocate for children with special health care needs — to guide outreach strategies, refine recruiting flyers, and help frame listening session questions with a health literacy and cultural competency lens.

In addition to ensuring cultural and linguistic competency, it is also important to use trauma-informed approaches. While states want to improve their systems, individuals who participate in improvement efforts in any capacity may be asked to relive and share about a time in their life that may have been traumatic. Given the level of sensitivity, it may be helpful for states to partner with individuals with expertise with trauma-informed approaches to avoid or minimize re-traumatization. For example, given the focus on pregnant individuals impacted by SUD — a group that is often stigmatized — the Alaska state team partnered with an SUD expert familiar with trauma-informed care to help inform the journey mapping process.

Using a broad cross-sector approach is also important to identify appropriate language in engagement efforts and develop shared goals across sectors. The Nevada team wanted to gauge families’ understanding of home-visiting programs and other services that support breastfeeding, nutrition, and relationship building between infants and caregivers. Prior to the family listening sessions, the state team workshopped questions and prompts with cross-agency staff and various community partners and providers to ensure that the right language was used to engage families.

4. Co-Create Solutions and Foster Feedback Loops with Families

When designing solutions for policy and systems change, states can involve families to help co-create solutions that better address their needs. The North Dakota team, which included Medicaid and the Department of Health and Human Services staff, selected a research-focused partner, the Department of Indigenous Health at the University of North Dakota School of Medicine and Health Sciences, to administer a survey and conduct focus groups with Medicaid beneficiaries to identify barriers and misperceptions around accessing and valuing well-child visits. Understanding what parents and caregivers deemed to be the biggest barriers to accessing well-child visits led to discussions with families about potential solutions to overcome those barriers. Solutions proposed included: (1) development of a Medicaid app so families could easily access benefits information and receive well-visit and vaccinations notices; (2) creation of a case manager chat feature on the state website to enable real-time referrals to services across systems as needed; and (3) a reframing of “child” well-visits to make it clear that adolescents also benefit from yearly pediatrician visits.

In addition, as changes are implemented, letting families know their instrumental role in improvements and systems change is important. The North Dakota team, with their university partner, created a plan to share a summary of lessons from their engagement efforts with the families who participated, as well as potential changes being considered based on shared family solutions. Since alignment work is a continuous process that benefits from ongoing monitoring and evaluation, it is important to set up recurring engagement activities with families to review and refine policy and program decisions and implementation steps. When families feel heard and included, it helps foster trust in the systems and providers who care for them, which in turn can lead to improved health outcomes.

Conclusion

Alignment of child health and social services is best done with families in mind and at the table from the beginning and throughout. By incorporating their input and putting community-driven solutions derived from beneficiaries and their families into place, state agencies can better align programs and services so that young children and their caregivers can receive higher quality and more tailored services to help promote healthier children, families, and communities. Aligning early childhood and Medicaid systems provides an opportunity for agency staff to think holistically about the programs they administer and to use beneficiaries and their families’ priorities as well as provider input to guide improvement efforts and system change.