Peer-reviewed article

Redesigning Primary Care Via Health Systems and Communities.

Kelleher KJ, Hardy R, Chavez L · 15 Sept 2026

Abstract

Objective Traditional primary care practices have not adequately adapted to the clear consensus on the importance of community and social factors in child health. Methods We describe how primary care can improve child and community health through community partnerships that integrate social care into healthcare systems. Specifically, we discuss a National Academy of Medicine heuristic for social care integration into practice and provide examples of primary care/social care integration. Practices/clinicians may feasibly address community and social factors through individual-level social care integration into practice. Larger groups of practices, health systems, and integrated networks can address community-level social integration efforts into medical care. Results Successful social care integration and related partnerships are contingent on a) an asset-based community development approach, b) maximizing community and partner participation, c) employing data driven improvement processes, and d) developing sustainable workforce and finance supports for the partnership activities. Conclusions Best outcomes for children and families will require a transformed primary care approach that addresses community needs through integration of social care and partners. Primary care change is hard, but accommodation and advocacy changes should be accessible to almost all primary care. Direct assistance and alignment activities likely require significant resources and the participation of larger networks and health systems. These last two activities may also require alternative payment models.