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Medical Homes and Young Children: Glossary of Terms
This glossary provides additional definitions and context for a number of terms used in the May
2012 Build paper, Medical Homes and Young Children.
Anticipatory guidance. As used in the medical world and applied to pediatric practices,
“anticipatory guidance” is an expected component of well-child care that involves the
practitioner giving the parents information about what to expect regarding the child’s growth
and development. It recognizes the role of the child health practitioner in helping to educate
and support parents to support their child’s growth and development and know when to seek
help. Bright Futures (see definition of “evidence-informed guidelines”) provides detailed
guidance to child health practitioners on providing anticipatory guidance, organized by the
child’s age and developmental trajectories.
Care coordination. Care coordination generally refers to the role a specific individual (care
coordinator) takes on to ensure that the child and family receive the services and supports
needed to address child’s health and development concerns and that these services are
themselves coordinated. Where young children are concerned, this may involve connecting the
family as well as the child to services and supports, responding to “social determinants of
health” (see definition) as well as biomedical determinants. To do so often requires additional
understanding of the family situation beyond that obtained by the primary practitioner and the
capacity to connect the family to services outside the medical community with which the
primary practitioner is most familiar. There is increasing emphasis in providing care
coordination to delineate the role of the care coordinator in independently getting to know and
build a relationship with the family and in ensuring that care coordination extends beyond
recommending possible services to providing “clinical referrals for care” (see definition). While
care coordination for patients with chronic or complex medical conditions may focus primarily
on ensuring the coordination across different clinical services, care coordination for young
children often involves linkages to a variety of services and supports to strengthen “protective
factors” (see definition).
Child health outcomes. The medical community has adopted a very broad definition of child
health: “the extent to which individual children or groups of children are able or enabled to (a)
develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that
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allow them to interact successfully with their biological, physical, and social environments.”
This moves well beyond the clinical treatment of disease or injury or health maintenance in the
context of existing health conditions. As applied to very young children, this effectively
encompasses the five domains of school readiness established in the educational world:
physical health and motor development, social and emotional development, approaches to
learning, language and literacy development, and general cognition. This does not mean that
the child health practitioner is solely responsible for meeting these goals for child health for the
practitioner’s patients – but it does mean that the practitioner has some responsibility to
contribute to the identification of concerns (see definition of “developmental surveillance”) and
a first response to them, in the context of what is available.
Clinical referral for care. When a primary health practitioner makes a referral of a patient to a
sub-specialist, the practitioner generally expects three things to occur. First, an appointment
with the sub-specialist will be scheduled. Second, the primary health practitioner will be
provided information on the appointment and any subsequent treatment. Third, the primary
health practitioner will continue to provide primary care and be part of subsequent decisions
about the patient’s ongoing care and treatment. Clinical care referrals go beyond making
recommendations for possible services to scheduling and following up on them. In the human
services world, referrals often mean simply suggesting other services. It is very important to
define what “referrals” entail in developing “care coordination” (see definition) strategies.
Developmental screening. When practitioners conduct well-child visits, they must assess where
children are on developmental trajectories related to physical, cognitive, social, and emotional
development. This involves “developmental screening,” an organized set of activities for
identifying a broad range of potential developmental issues and concerns both through direct
observation and testing of the child and through gathering information from parents, through
such developmental screening tools as Ages and Stages or PEDs. These are generally brief tools
that help to indicate whether there may be a problem or concern, and are not a diagnosis. Such
screening can lead to recommendations for more detailed assessments (such as referrals to
Part C early intervention programs for diagnosis of developmental delays or to a mental health
specialist for diagnosis of mental health conditions such as autism spectral disorders), to
additional or focused anticipatory guidance around certain issues, or to care coordination for
additional preventive or developmental supports.
Developmental surveillance. Developmental surveillance is the ongoing process of getting the
“big picture” on children’s development, with particular attention to eliciting parent concerns
and monitoring psychological and social risk factors that can deter development. While
developmental screening is often a part of developmental surveillance, developmental
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surveillance is a broader concept. The AAP recommends both developmental screening and
developmental surveillance.
Evidence-informed guidelines (Bright Futures). The Affordable Care Act requires all insurers to
cover primary and preventive health services for young children, based on “evidence-informed
guidelines” established by the federal Health Services and Resources Administration (HRSA).
This is a reference to Bright Futures, a comprehensive set of guidelines and protocols for wellchild visits developed by the American Academy of Pediatrics – which incorporates detailed
recommendations for “anticipatory guidance” (see definition) to address all aspects related to
“child health outcomes” (see definition). Federal recognition of Bright Futures as an expected
standard of care is an important step to fostering child health practices that meet the goals for
“child health outcomes” (see definition).
Life course model of health. This term has been incorporated into the Institute of Medicine’s
Children’s Health: The Nation’s Wealth report and its set of recommendations for improving
child health status. The “life course model” recognizes the interplay and interdependence
between biology, behavior, social environment, and physical environment in children’s health
and the trajectory of child health over time. The latter suggests the critical importance of
setting a positive trajectory in the earliest years of life as the scaffolding for future
development.
Medical home (patient-centered medical home, health home. A common-sense definition, as
applied to patients generally, is a health practitioner or office providing ongoing and continuous
primary and routine care for a patient, as well as overseeing any subspecialty care needed by
the patient. Often referred to as a “patient-centered medical home,” the medical home
practitioner or office is expected to establish a relationship with the patient that is on a
continuing basis, find out and know the patient’s medical history and context, and involve the
patient in making decisions about care and treatment. The term “health home” is an effort to
ensure the definition extends beyond medical and clinical care.
Population health. “Population health” refers to the health of populations or groups of people,
which may be defined geographically, by age, gender, ethnicity, socio-economic background, or
any other factor. By examining population health, it may be possible to identify factors within
the larger community or society that contribute to the health of the population as a whole and
which involve responses that go beyond individual patient actions. This can include different
“social determinants of health” (see definition), such as discrimination and social exclusion or
the presence of toxins in the neighborhood. The medical home involves the health
practitioner’s ongoing relationship with specific patients and providing them with individual
services, but the medical home also can act beyond caring for individual patients to taking a
role in the community to address larger population health issues and concerns.
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Resilience. Resilience, or the ability to bounce back from setbacks, represents an orientation to
life and the world that strongly contributes to health. According to the research, some children
are more naturally resilient than others, but the child’s environment can foster greater
resiliency. Further, children do better in families where their parents themselves are resilient.
Children or adults who have experienced “toxic stress” (see definition) are much less likely to
exhibit resiliency and be much more likely to experience poor health outcomes.
Risk and Protective Factors. Risk and protective factors have been used in the juvenile justice
and substance abuse world for decades to help to explain social deviancy, and have many
similarities with the “social determinants of health” (see definition) and “resiliency” (see
definition) literatures. Increasingly, states are using the Strengthening Families protective
factor framework in developing early childhood services. That framework identifies five
protective factors associated with child abuse prevention among young children: (1) parental
resilience, (2) social connections, (3) concrete support in times of need, (4) knowledge of
parenting and child development, and (5) social and emotional competence of children.
Social determinants of health. Social determinants of health refer to those factors that
contribute to health that are social, and not biomedical, in nature. The term is in particular use
in international efforts to improve children’s health, drawing upon a large a multi-disciplinary
research base to define determinants that contribute to good and poor health. The World
Health Organization’s Social Determinants of Health: The Solid Facts enumerates ten social
determinants: (1) the social gradient (resource/opportunity inequality), (2) stress, (3) early life
(e.g. life course developmental trajectory), (4) social exclusion, (5) work, (6) unemployment, (7)
social support, (8) addiction, (9) food, and (10) transport.
Toxic Stress, Early Childhood Adversity, and Adverse Childhood Experiences. Toxic stress is a
term employed by the Center for the Development Child to describe severe, prolonged, and/or
unmitigated stress (usually related to abuse, neglect, or parental stress) on young children and
its profound adverse impact on brain development. Toxic stress is triggered by early childhood
adversity, but adversity and stress alone do not necessarily lead to toxic stress, provided there
are sufficient compensating, nurturing, and supporting protective factors. Research on Adverse
Childhood Experiences (ACEs – as reported by adults regarding their childhood experiences),
has shown that multiple adverse childhood experiences are associated with greater adult
morbidity and risky health behaviors, with those findings applying to persons of higher as well
as lower socio-economic status. In general, the literature on toxic stress, early childhood
adversity, and adverse childhood experiences points to the importance of prevention and early
intervention to strengthen protective factors in children’s lives and address social determinants
of health that can adversely impact them.
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