Screening and Referral for Low-Income Families' Social Determinants of Health by US Pediatricians

Characteristics Associated With Positive Social Determinants of Health Screening in Patients Admitted to Pediatric Hospital Medicine

BACKGROUND AND OBJECTIVE

There is limited research on screening for social determinants of health (SDOH) in hospitalized pediatric patients. In this article, we describe patient characteristics related to SDOH screening in the hospital setting and examine relationships with acute care metrics.

METHODS

This is a retrospective cohort study. From July 2020 to October 2021, a 14-question SDOH screener was administered to families of patients admitted or transferred to the hospital medicine service. Information was collected regarding screen results, demographics, patient comorbidities, patient complexity, and acute care metrics. Unadjusted and multivariable analyses were performed using generalized estimation equation logistic regression models.

RESULTS

Families in 2454 (65%) patient encounters completed SDOH screening, with ≥1 need identified in 662 (27%) encounters. Families with significant odds for positive screening results in a multivariable analysis included primary language other than English (odds ratio [OR] 4.269, confidence interval [CI] 1.731-10.533) or Spanish (OR 1.419, CI 1.050-1.918), families identifying as "Black" (OR 1.675, CI 1.237-2.266) or Hispanic (OR 1.347, CI 1.057-1.717) or having a child on the complex care registry (OR 1.466, CI 1.120-1.918). A positive screening result was not associated with increased length of stay, readmission, or 2-year emergency department or acute care utilization.

CONCLUSIONS

In hospitalized pediatric patients, populations at the greatest odds for positive needs include families with primary languages other than English or Spanish, those that identified as certain races or ethnicities, or those having a child on the complex care registry. A positive SDOH screening result in this study was not associated with an increase in length of stay, readmission, or acute care utilization.

Parent Perspectives on Social Risk Screening in the PICU

OBJECTIVE

Health inequities are widespread and associated with avoidable poor health outcomes. In the PICU, we are increasingly understanding how health inequities relate to critical illness and health outcomes. Experts recommend assessing for health inequities by screening for social determinants of health (SDOH) and adverse childhood experiences (ACEs); however, guidance on screening is limited and screening has not been universally implemented. Our study aimed to understand parent perspectives on screening for SDOH/ACEs in the PICU, with the primary objective of determining whether screening would be acceptable in this setting.

DESIGN

We conducted a qualitative study using semistructured interviews with a convenience sample of eleven PICU parents between November 2021 and January 2022.

SETTING

Urban, quaternary free-standing children's hospital.

SUBJECTS

Parents of children with a PICU hospitalization between November 2020 and October 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Domains of interest included experience with and attitudes toward SDOH/ACEs screening, perspectives on addressing needs with/without resources and their relationship to health, and recommendations for screening. Interviews were transcribed verbatim and coded with an inductive approach using thematic analysis and constant comparative methods. Ann & Robert H. Lurie Children's Institutional Review Board approved this study (2021- 4781, Approved September 13, 2021). Ten participants found SDOH/ACEs screening to be acceptable and valuable in the PICU, even for topics without a readily available resource. Participants did not have broad experience with ACEs screening, though all believed this provided the medical team with valuable context regarding their child. Ten participants recommended screening occur after their child has been stabilized and that they are notified that screening is universal.

CONCLUSIONS

Participants found screening for SDOH/ACES to be acceptable and valuable in the PICU. Families have important insight that should be leveraged to improve the support of unmet needs through the development of strengths-based, parent-informed screening initiatives.

Early Childhood Screening Practices and Barriers: A National Survey of Primary Care Pediatricians

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening during the first 3 years of life for developmental risk/delay, maternal depression, and social determinants of health (SDOH) using standardized tools. Adoption of these guidelines has been gradual, and barriers to screening are as varied as pediatric practices are themselves.

METHODS

We analyzed 2019 American Academy of Pediatrics Periodic Survey data. The survey included pediatricians' screening practices for developmental delay, maternal depression, and SDOH, and barriers to screening. We used Cochran's Q and McNemar's tests to compare barriers across topics, and χ2 tests and multivariable logistic regression to examine the relationship between barriers and screening practices.

RESULTS

The survey response rate was 46.9% (n = 688). Most pediatricians reported screening/surveilling for developmental delay (98.1%), maternal depression (83.2%), and SDOH (76.7%), but fewer used standardized instruments to do so (59.0%, 44.9%, 12.6%, respectively). Those not screening/only surveilling for maternal depression were more likely to report that screening is not an appropriate role for the pediatrician and difficulty prioritizing time. For SDOH, those not screening/only surveilling were more likely to report instruments not available in the electronic health record, lack of knowledge regarding referral options, and lack of treatment options for positive screens.

CONCLUSIONS

Rates of standardized screening, and barriers pediatricians encounter, have important implications for improving quality of early childhood preventive care. Opportunities include expanding the primary care team and integrating screening tools into the electronic health record. Programs to support social needs and maternal mental health could be strengthened to ensure robust referral options are available.

The Pediatrician's Role in Preventing Child Maltreatment: Clinical Report

Pediatricians have always seen the value of preventing health harms; this should be no less true for child maltreatment than for disease or unintentional injuries. Research continues to demonstrate that maltreatment can be prevented, underscoring the vital roles of both the family and society in healthy childhood development and the importance of strong, stable, nurturing relationships in preventing maltreatment and building the child's resilience to adversity. This clinical report elaborates the pediatrician's multitiered role in supporting relational health from infancy through adolescence, from universal interventions assessing for maltreatment risks and protective factors to targeted interventions addressing identified needs and building on strengths. When maltreatment has already occurred, interventions can prevent further victimization and mitigate long-term sequelae. Advice is provided on engaging community resources, including those that provide food, shelter, or financial support for families in need.

Comparing Two Training Modalities Supporting the Adoption of the SEEK Approach in Pediatric Primary Care 6/30/24

OBJECTIVE

To compare the impact of two common continuing medical education training modalities - independent online training (IND) and a Maintenance of Certification-4 activity (MOC) - on primary care professionals' (PCPs') thinking and practice behavior regarding the Safe Environment for Every Kid (SEEK) approach. This was part of an implementation science study scaling up the evidence-based practice, SEEK.

METHODS

This is a longitudinal, multi-site, mixed methods, cluster randomized controlled trial comparing 21 pediatric primary care practices across the U.S. randomized to one of two training modalities. Two hundred and ten PCPs completed surveys up to 4 times over a two-year period to assess their thinking and practice regarding SEEK; a subset was interviewed up to 3 times.

RESULTS

Training led to significant and sustained improvements in PCPs' thinking and behavior related to SEEK, with no significant differences between the IND and MOC groups. PCPs mostly viewed their training positively, but several described shortcomings. PCP characteristics, such as age and sex, did not moderate the impact of the training, nor did the presence of a behavioral health professional.

CONCLUSIONS

The lack of significant differences between the training modalities favors the simpler IND modality. This was despite the MOC training employing key principles of adult education. Of note, MOC-4 credits are required for pediatric board certification. More research is needed to optimize continuing medical education and to tailor approaches for different learners.

Pediatric Primary Care of Children With Intrauterine Opioid Exposure: Survey of Academic Teaching Practices

OBJECTIVE

Intrauterine opioid exposure (IOE) has increased over the last 2 decades and is associated with additional needs after birth. To date, no clinical guidelines address the primary care of children with IOE. We aimed to characterize clinician-reported screening and referral practices, barriers to effective primary care for children with IOE, and clinician- and practice-level characteristics associated with perceived barriers.

METHODS

We conducted a cross-sectional survey of pediatric residents, pediatricians, and advanced practitioners at 28 primary care clinics affiliated with 7 pediatric residency programs (April-June 2022). We assessed screening and other clinical practices related to IOE and perceived barriers to addressing parental opioid use disorder (OUD). We used descriptive statistics to analyze survey responses, assessed the distribution of reported barriers, and applied a 2-stage cluster analysis to assess response patterns.

RESULTS

Of 1004 invited clinicians, 329 (32.8%) responses were returned, and 325 pediatric residents and pediatricians were included in the final analytic sample. Almost all (99.3%) reported parental substance use screening as important, but only 11.6% screened routinely. Half of the respondents routinely refer children with IOE to early intervention services and social work. Lack of standard screening for substance use was the most frequently selected barrier to addressing parental OUD. Participants reporting fewer barriers to addressing parental OUD identified having greater access to OUD treatment programs and home visiting programs.

CONCLUSIONS

Pediatricians report variations in primary care screenings and referrals for children with IOE. Access to parental OUD treatment programs may mitigate perceived barriers to addressing parental OUD in the pediatric office.

Addressing food insecurity in rural primary care: a mixed-methods evaluation of barriers and facilitators

BACKGROUND

Food insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices.

METHODS

We conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes.

RESULTS

Participants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were "very important" for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming.

CONCLUSIONS

Rural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI.

The Health Equity Explorer: An open-source resource for distributed health equity visualization and research across common data models

Introduction

There is an urgent need to address pervasive inequities in health and healthcare in the USA. Many areas of health inequity are well known, but there remain important unexplored areas, and for many populations in the USA, accessing data to visualize and monitor health equity is difficult.

Methods

We describe the development and evaluation of an open-source, R-Shiny application, the "Health Equity Explorer (H2E)," designed to enable users to explore health equity data in a way that can be easily shared within and across common data models (CDMs).

Results

We have developed a novel, scalable informatics tool to explore a wide variety of drivers of health, including patient-reported Social Determinants of Health (SDoH), using data in an OMOP CDM research data repository in a way that can be easily shared. We describe our development process, data schema, potential use cases, and pilot data for 705,686 people who attended our health system at least once since 2016. For this group, 996,382 unique observations for questions related to food and housing security were available for 324,630 patients (at least one answer for all 46% of patients) with 65,152 (20.1% of patients with at least one visit and answer) reporting food or housing insecurity at least once.

Conclusions

H2E can be used to support dynamic and interactive explorations that include rich social and environmental data. The tool can support multiple CDMs and has the potential to support distributed health equity research and intervention on a national scale.

Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States

BACKGROUND

While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US).

METHODS

This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance.

RESULTS

A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH.

CONCLUSION

Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

Parent and grandparent neonatal intensive care unit visitation for preterm infants

OBJECTIVE

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes.

STUDY DESIGN

Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared.

RESULTS

Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%).

CONCLUSION

Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Addressing adverse social determinants of health in pediatric primary care: Study protocol for a hybrid type 2 effectiveness-implementation randomized controlled trial in two national pediatric practice-based research networks

BACKGROUND

Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices.

METHODS

We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases.

DISCUSSION

Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.

Social Determinants of Health and Allergic Disease Prevalence Among Asian American Children

BACKGROUND

Although racial and ethnic disparities in allergic diseases have previously been observed, the relationship between social determinants of health (SDoH) and allergic disease prevalence among disaggregated Asian American (AsA) subgroups is poorly understood.

OBJECTIVE

To examine the association of SDoH with allergic disease prevalence among disaggregated AsA subgroups.

METHODS

Using the 2011-2018 National Health Interview Survey, we examined caregiver-reported race and ethnicity, SDoH, and allergic diseases. We compared survey-weighted allergic disease prevalence by AsA subgroup. Subgroup-stratified multivariable logistic regression accounting for age, sex, child/parent nativity, and survey year modeled the association between SDoH and allergic disease prevalence. We provide predicted probabilities of having each allergic disease based on exposure to each SDoH.

RESULTS

We examined data from 5042 non-Hispanic AsA children representing 3,264,768 AsA children. Approximately 25% of all AsA children reported at least one allergic disease, ranging from 20% of Asian Indian children to 30% of Filipino/a children. The number of unfavorable SDoH was lowest among Asian Indian and Chinese children (mean 0.7) and highest among "other Asian" children (mean 1.2). In stratified analyses, financial instability and inaccessible healthcare were associated with greater probability of allergic diseases among some, but not all AsA subgroups. Lower parent education level, food insecurity, and rent/other housing arrangement were associated with lower probability of allergic disease among some AsA children.

CONCLUSION

There was heterogeneity in the association of SDoH and allergic disease prevalence among AsA children. Further study of SDoH may inform modifiable environmental factors for allergic disease among AsA children.

Accuracy of a Single Financial Security Question to Screen for Social Needs

OBJECTIVES

Screening for social needs is recommended during clinical encounters but multi-item questionnaires can be burdensome. We evaluate if a single question about financial stress can be used to prescreen for food insecurity, housing instability, or transportation needs.

METHODS

We use retrospective medical record data from children (<11 years) seen at 45 primary pediatric care offices in 2022. Social needs screening was automated at well child visits and could be completed by the parent/guardian via the patient portal, tablet in the waiting room, or verbally with staff. We report the area under the receiver operating curve for the 5 response options of the financial stress question as well as sensitivity and specificity of the financial stress question ("not hard at all" vs any other response) to detect other reported social needs.

RESULTS

Of 137 261 eligible children, 130 414 (95.0%) had social needs data collected. Seventeen percent of respondents reported a housing, food, or transportation need. The sensitivity of the financial stress question was 0.788 for any one or more of the 3 other needs, 0.763 for food insecurity, 0.743 for housing instability, and 0.712 for transportation needs. Using the financial stress question as the first-step of a screening process would miss 9.7% of the families who reported food insecurity, 22.6% who reported housing instability, and 33.0% who reported transportation needs.

CONCLUSIONS

A single question screener about financial stress does not function well as a prescreen because of low sensitivity to reports of food insecurity, housing instability, and transportation needs.

Community Health Center Staff Perspectives on Financial Payments for Social Care

Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee-for-service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee-for-service payments are unlikely to strongly influence CHC social care practices.

CONTEXT

A growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients' social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities.

METHODS

We interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches.

FINDINGS

We grouped findings into three categories: participants' awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well.

CONCLUSIONS

Small fee-for-service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives-e.g., by increasing clinical teams' awareness of incentives, linking screening to well-funded social services, and changing incentive amounts to support social care staffing needs-may increase the uptake of social care practices in CHCs.

Screening for the social determinants of health: Referring patients to community-based services

BACKGROUND

Screening patients for the social determinants of health (SDOH) allows clinicians to identify those needs and tailor referral efforts. Due to constraints on clinic time and monetary resources, a simple screening tool incorporated into existing clinic workflow increases its usefulness and impact.

LOCAL PROBLEM

Our free, nurse-led, mobile health clinic (MHC) needed an enhanced process or tool for screening patients for SDOH. The purpose of this quality-improvement project was to screen adult patients in the MHC for SDOH needs and to increase volunteer staff perceptions of their knowledge and confidence in referring patients to relevant community-based services.

METHODS

A screening process and tool was developed using guidelines from the Health Leads to identify patients' SDOH needs and related requests for assistance. The tool was introduced to and tested among volunteer staff through pretest/posttest surveys.

INTERVENTIONS

Patients who visited the clinic were screened for the SDOH within the project period, and volunteer staff were surveyed about their perceptions of the screening tool.

RESULTS

Sixty-four patients were screened for SDOH needs. Twenty-three percent reported food insecurity, 27% housing insecurity, 14% difficulty obtaining utilities, and 17% difficulty obtaining transportation; 28% requested assistance with their reported SDOH needs. Seventeen percent of patients reported two or more SDOH needs. At posttest, 100% of volunteer staff ( N = 9) indicated satisfaction with the SDOH screening questions, reported feeling knowledgeable about resources to use for patient referrals, and were confident in referring patients to needed resources.

CONCLUSION

The screening tool aptly guided practice and was evaluated as "easy to use" for clinic patients and volunteer staff.

Feasibility of linking universal child and family healthcare and financial counselling: findings from the Australian Healthier Wealthier Families (HWF) mixed-methods study

OBJECTIVES

'Healthier Wealthier Families' (HWF) seeks to reduce financial hardship in the early years by embedding a referral pathway between Australia's universal child and family health (CFH) services and financial counselling. This pilot study investigated the feasibility and short-term impacts of HWF, adapted from a successful Scottish initiative.

METHODS

Setting: CFH services in five sites across two states, coinciding with the COVID-19 pandemic.

PARTICIPANTS

Caregivers of children aged 0-5 years experiencing financial hardship (study-designed screen).

DESIGN

Mixed methods. With limited progress using a randomised trial (RCT) design in sites 1-3 (March 2020-November 2021), qualitative interviews with service providers identified implementation barriers including stigma, lack of knowledge of financial counselling, low financial literacy, research burden and pandemic disruption. This informed a simplified RCT protocol (site 4) and direct referral model (no randomisation, pre-post evaluation, site 5) (June 2021-May 2022).

INTERVENTION

financial counselling; comparator: usual care (sites 1-4). Feasibility measures: proportions of caregivers screened, enrolled, followed up and who accessed financial counselling. Impact measures: finances (quantitative) and other (qualitative) to 6 months post-enrolment.

RESULTS

355/434 caregivers completed the screen (60%-100% across sites). In RCT sites (1-4), 79/365 (19%-41%) reported hardship but less than one-quarter enrolled. In site 5, n=66/69 (96%) caregivers reported hardship and 44/66 (67%) engaged with financial counselling; common issues were utility debts (73%), and obtaining entitlements (43%) or material aid/emergency relief (27%). Per family, financial counselling increased income from government entitlements by an average $A6504 annually plus $A784 from concessions, grants, brokerage and debt waivers. Caregivers described benefits (qualitative) including reduced stress, practical help, increased knowledge and empowerment.

CONCLUSIONS

Financial hardship screening via CFH was acceptable to caregivers, direct referral was feasible, but individual randomisation was infeasible. Larger-scale implementation will require careful, staged adaptations where CFH populations and the intervention are well matched and low burden evaluation.

TRIAL REGISTRATION NUMBER

ACTRN12620000154909.

Assessment of Adoption and Early Implementation Barriers and Facilitators of the Safe Environment for Every Kid (SEEK) Model

OBJECTIVE

Although the use of interventions for screening for social determinants of health of families in pediatric primary care clinics has increased in the past decade, research on the barriers and facilitators of implementing such interventions has been limited. We explored barriers, facilitators, and the mechanisms clarifying their roles in the adoption and implementation of the Safe Environment for Every Kid (SEEK) model, an approach for strengthening families, promoting children's health and development, and preventing child maltreatment.

METHODS

A total of 28 semistructured interviews were completed with 9 practice champions, 11 primary care professionals, 5 behavioral health professionals, and 3 nursing/administrative staff representing 12 pediatric primary care practices participating in a larger randomized control trial of implementing SEEK.

RESULTS

We identified several barriers and facilitators in the stages of SEEK's adoption and early implementation. Barriers associated with outer and inner setting determinants and poor innovation-organization fit declined in importance over time, while facilitators associated with SEEK characteristics increased in importance based on participants' responses. Barriers and facilitators were linked by mechanisms of comparison and contrast of burdens and benefits, and problem-solving to address limited capacity with available resources.

CONCLUSIONS

Any screening for and addressing social determinants of health demands greater attention to adoption and implementation mechanisms and the processes by which primary care professionals assess and utilize facilitators to address barriers. This occurs in a context defined by perceived burdens and benefits of innovation adoption and implementation, the capacity of the practice, and changes in perception with experiencing the innovation.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study

OBJECTIVE

Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation.

METHODS

We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data.

RESULTS

Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data.

CONCLUSIONS

This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study

Introduction

Interventions to address social needs in clinical settings can improve child and family health outcomes. Electronic health record (EHR) tools are available to support these interventions but are infrequently used. This mixed-methods study sought to identify approaches for implementing social needs interventions using an existing EHR module in pediatric primary care.

Methods

We conducted focus groups and interviews with providers and staff (n = 30) and workflow assessments (n = 48) at four pediatric clinics. Providers and staff completed measures assessing the acceptability, appropriateness, and feasibility of social needs interventions. The Consolidated Framework for Implementation Research guided the study. A hybrid deductive-inductive approach was used to analyze qualitative data.

Results

Median scores (range 1-5) for acceptability (4.9) and appropriateness (5.0) were higher than feasibility (3.9). Perceived barriers to implementation related to duplicative processes, parent disclosure, and staffing limitations. Facilitators included the relative advantage of the EHR module compared to existing documentation practices, importance of addressing social needs, and compatibility with clinic culture and workflow. Self-administered screening was seen as inappropriate for sensitive topics. Strategies identified included providing resource lists, integrating social needs assessments with existing screening questionnaires, and reducing duplicative documentation.

Conclusions

This study offers insight into the implementation of EHR-based social needs interventions and identifies strategies to promote intervention uptake. Findings highlight the need to design interventions that are feasible to implement in real-world settings. Future work should focus on integrating multiple stakeholder perspectives to inform the development of EHR tools and clinical workflows to support social needs interventions.

Innovations in social health delivery to advance equitable pediatric and adolescent life course health development: A review and roadmap forward

Recognizing the influence of social determinants on health and development, health care has increasingly advocated for interventions that target upstream factors as part of routine pediatric care delivery. In response, clinic-based social risk screening and referral programs have proliferated wherein patients are screened for health-related social needs (HRSNs, such as food and housing insecurity) and referred to community-based organizations (CBOs) and social service providers to address those needs. In recent years, an array of digital platforms, known as Social Health Access and Referral Platforms (SHARPs), have emerged to facilitate the scale and implementation of these models amidst growing system demand. Recent evidence on the effectiveness of social risk screen and refer models and SHARPs has been mixed, giving researchers pause and calling for more nuanced understanding of the limitations of such models, especially for promoting child and family health. Design thinking informed by the Life-Course Health Development (LCHD) framework provides a particularly useful lens for synthesizing emerging limitations of such models in the pediatric context, given the dynamic and developmentally-driven circumstances that shape family health and well-being in the early life course. By (1) focusing on addressing deficits-based social risks, (2) scoping to act upon narrow, downstream needs, (3) timing to react to social needs that have already caused harm rather than preventing them, and (4) limiting scale to individual-by-individual responses rather than structural and population-wide interventions, the current design of prevailing social risk screen and refer programs fundamentally limits their potential impact and misses opportunities to improve health equity over the life course. How can health care, social care, and technology partners move forward in collaboration with families and communities to better support equitable lifelong health and social development? In this narrative review, we will summarize the current design, implementation, and limitations of the predominant social risk screen and refer approach in the context of early childhood and adolescent care delivery. We then will apply LCHD principles to advance and improve on this approach from a reactionary focus towards a Family Journey Model that better supports life course health development.

Preliminary Pilot-Testing of Social Determinants of Health Screener for Individuals With Intellectual and Developmental Disabilities in Med-Peds

In the United States, one in six children has an intellectual and/or developmental disability (I/DD), including attention deficit hyperactivity disorder (ADHD), autism, cerebral palsy, learning disabilities, seizures, and developmental delays, with or without intellectual impairment. Individuals with I/DDs experience disproportionate rates of immune, metabolic, cardiovascular, and neurological disorders, as well as anxiety, depression, functional somatic symptoms, and other co-occurring physical and mental health conditions. During the coronavirus disease 2019 (COVID-19) pandemic, having an I/DD emerged as one of the strongest predictors of contracting and dying from COVID-19. These findings spurred increased attention toward the myriad health inequities affecting this population well before the pandemic. While inequities for individuals with I/DD can be traced to many factors, social determinants of health (SDOH) - the underlying social, economic, and environmental conditions that lead to poor health outcomes and high healthcare costs - are key contributors. Our interdisciplinary combined internal medicine and pediatrics (Med-Peds) team of physicians, psychologists, and researchers within a large, diverse, academic health system aimed to pilot-test the implementation of a five-item SDOH screener within a Med-Peds specialty clinic focused on the developmental needs of individuals with I/DD and their families (Leadership Education in Neurodevelopmental Disabilities {LEND}) and a general primary care practice (PCP). The SDOH screener tested in this initiative includes five items from the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool (HRSN) assessing social isolation, food insecurity, transportation, and paying for basic needs, such as housing and medical care. In this study, we describe the process of implementing this screener and collecting initial pilot data from 747 patients between October 2022 and April 2023 across the LEND and the primary care practice. We also highlight the challenges and opportunities identified during the mid-way point of implementation and pilot testing. The results of this pilot study revealed low response rates among SDOH screeners, spurring several measures to increase uptake, including increasing the accessibility of the screener and ensuring the screener results in effective referrals. We call on additional Med-Peds healthcare teams without universal SDOH screening protocols in place - particularly those serving the I/DD population - to consider adopting these practices.

Evictions and Infant and Child Health Outcomes: A Systematic Review

Importance

Millions of rental evictions occur in the United States each year, disproportionately affecting households with children. Increasing attention has been paid to the impact of evictions on child health outcomes.

Objective

To synthesize and assess studies examining the associations of eviction exposure with infant and child health outcomes.

Evidence Review

For this systematic review without meta-analysis, a database search was performed using PubMed, Web of Science, and PsycINFO, through September 25, 2022. Included studies were peer-reviewed quantitative studies examining an association between exposure to eviction and at least 1 health outcome, both before age 18 years, including prenatal exposures and perinatal outcomes. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data were analyzed from March 3 to December 7, 2022.

Findings

Database searches identified 266 studies, and 11 studies met inclusion criteria. Six studies examined associations between prenatal eviction and birth outcomes, such as gestational age, and each found that eviction was significantly associated with at least 1 adverse birth outcome. Five studies investigated other childhood outcomes, including neuropsychological test scores, parent-rated child health, lead testing rates, and body mass index, and among these 5 studies, 4 reported an association between eviction and adverse child health outcomes. Direct experience of eviction or residence in a neighborhood with more evictions was associated with adverse perinatal outcomes in 6 studies, higher neurodevelopmental risk in 2 studies, worse parent-rated child health in 2 studies, and less lead testing in 1 study. Study designs and methods were largely robust.

Conclusions and Relevance

In this systematic review without meta-analysis of the association between evictions and child health outcomes, evidence demonstrated the deleterious associations of eviction with a range of developmental periods and domains. In the context of a rental housing affordability crisis, ongoing racial disparities in evictions, and continuing harm to millions of families, health care practitioners and policy makers have an integral role to play in supporting safe, stable housing for all.

Screening for Social Determinants of Health in the Pediatric Intensive Care Unit: Recommendations for Clinicians

Social determinants of health (SDoH) play a significant role in the health and well-being of children in the United States. Disparities in the risk and outcomes of critical illness have been extensively documented but are yet to be fully explored through the lens of SDoH. In this review, we provide justification for routine SDoH screening as a critical first step toward understanding the causes of, and effectively addressing health disparities affecting critically ill children. Second, we summarize important aspects of SDoH screening that need to be considered before implementing this practice in the pediatric critical care setting.

The Association of Socioeconomic Vulnerability and Race and Ethnicity With Disease Burden Among Children in a Statewide Medicaid Population

OBJECTIVE

Individuals enrolled in Medicaid have disproportionately worse health outcomes due to challenges related to Social Determinants of Health. We aim to examine the prevalence of 3 childhood conditions (asthma, type 2 diabetes, and attention deficit hyperactivity disorder [ADHD]) in children within the Texas Medicaid system. In order to recognize the layers of vulnerability, we examine prevalence at the intersection of socioeconomic status with race and ethnicity within this economically challenged population.

METHODS

Children ages 0 to 17 were identified from claims and encounter data for all children enrolled in Texas Medicaid in 2017 for at least 6 months. All children were placed into one of 5 quintiles based on their census tract socioeconomic vulnerability. The Rate Ratio statistical test was employed to identify the statistical significance of the disparity in health outcomes related to higher neighborhood vulnerability within each racial or ethnic group.

RESULTS

Asthma for each race and ethnicity group was significantly more prevalent in the higher vulnerability census tracts. Increased vulnerability related to significant increase in type 2 diabetes for Hispanic children, but not for other groups. Diagnosed ADHD prevalence was significantly higher in less vulnerable non-Hispanic white children compared to more vulnerable.

CONCLUSIONS

This study found that even among children who receive Medicaid and are thus economically disadvantaged, socioeconomic vulnerability applies an additional burden within racial and ethnic groups to produce disparities in health-related burden. However, the trend of the relationship varied by race and ethnicity group and health condition.

Time Spent at Well-Child Care Visits for English- and Spanish-Speaking Parents

OBJECTIVE

To measure duration of well-child care (WCC) visits at 2 federally qualified health centers (FQHCs), across 10 clinic sites, and determine if differences exist in visit duration for English- and Spanish-speaking parents.

METHODS

Upon arrival to their child's 2- to 24-month well visit, a research team member followed families throughout their visit noting start and end times for a series of 5 WCC visit tasks. The average time to complete each visit task for the entire sample was then calculated. Mann-Whitney U tests were run to determine if task completion time differed significantly between English- and Spanish-speaking parents.

RESULTS

The total sample included 199 parents of infants and children between 2 and 24 months old. Over one third of the sample spoke Spanish as their primary language (37%). The average visit time was 77 minutes (standard deviation [SD] = 48). Median time spent with the clinician was 14 minutes (SD = 5). Clinician visit time was significantly different U = 2608, P < .001, r = 0.38 between English- (median = 15 minutes) and Spanish (median = 11 minutes)-speaking parents. No other significant differences were identified.

DISCUSSION

Our findings align with previous studies showing the average time spent with a clinician during a WCC visit was 15 minutes. Further, the average time with a clinician was less for Spanish-speaking parents. With limited visit length to address child and family concerns, re-designing the structure and duration of WCC visits is critical to best meet the needs of families living in poverty, and may ensure that Spanish-speaking parents receive appropriate guidance and support without time limitations.

"Why Do They Want to Know?": A Qualitative Assessment of Caregiver Perspectives on Social Drivers of Health Screening in Pediatric Primary Care

OBJECTIVE

Despite strong evidence that social factors have a large influence on child health, systematic screening for social needs is not performed universally in pediatric primary care. This is due to multiple barriers, including concerns about acceptability to families. This study sought to assess family acceptability of social needs screening in pediatric primary care.

METHODS

Eight semi-structured focus groups were performed with English and Spanish-speaking caregivers of pediatric patients from a diverse academic medical center. Focus groups explored the acceptability of social domains including housing, education, finances, food access, and safety. Focus group transcripts were qualitatively analyzed to identify themes.

RESULTS

Four salient themes emerged: 1) the acceptability of social determinants of health screening questions was tied to participants' understanding of the connection between the topic and child health, 2) families preferred a warm handoff to community services, 3) families feared child protective services intervention as a result of sharing unmet social needs, and 4) positive provider rapport was an important factor in choosing to share social needs.

CONCLUSIONS

Pediatric primary care providers should feel comfortable implementing social needs screening when they can clearly explain the connection to child health. They should become knowledgeable about organizations and partners within their communities and feel empowered to connect patients to these resources.

Examining the Implementation of Health-Related Social Need (HRSN) Screenings at a Pediatric Community Health Center

INTRODUCTION

Social determinants of health (SDoH) influence health outcomes and screening for health-related social needs (HRSN) is a recommended pediatric practice. In 2018, Denver Health and Hospitals (DH) implemented the Accountable Health Communities (AHC) model under the Centers for Medicare and Medicaid Services (CMS) and began using the AHC HRSN screening tool during selected well child visits (WCVs) at a DH Federally Qualified Health Center (FQHC). The current evaluation aimed to examine the program implementation and identify key lessons learned to inform the expansion of HRSN screening and referral to other populations and health systems.

METHODS

Patients who completed a WCV between June 1, 2020 and December 31, 2021 (N = 13 750) were evaluated. Frequencies and proportions were used to describe patient characteristics of those that had a WCV, were screened, and received resource information. Multivariable logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to determine the association between patient characteristics and completing HRSN screening and provision of resource information.

RESULTS

The screening tool was completed by 80% (n = 11 004) of caregivers bringing children to a WCV at the DH Westside Clinic, with over one-third (34.8%; n = 3830) reporting >1 social need. Food insecurity was the most common concern (22.3%; n = 2458). Non-English, non-Spanish (NENS) speakers were less likely to be screened (OR 0.43, 95% CI 0.33, 0.57) and less likely to report a social need (OR 0.59, 95% CI 0.42, 0.82) than speakers of English, after adjusting for age, race/ethnicity, and health insurance.

CONCLUSIONS

A high rate of screening indicates feasibility of administering HRSN screenings for pediatric patients in a busy FQHC. More than a third of patients reported one or more social needs, underscoring the importance to identity these needs and the opportunity to offer personalized resources. Comparatively lower rates of screening and potential underreporting among NENS may be indicative of the availability and acceptability of current translation procedures as well as how the tool translates linguistically and culturally. Our experience highlights the need to partner with community organizations and involve patients and families to ensure SDoH screening and care navigation is part of culturally-appropriate patient-centered care.

Seeking justice, equity, diversity and inclusion in pediatric nephrology

Inequity, racism, and health care disparities negatively impact the well-being of children with kidney disease. This review defines social determinants of health and describes how they impact pediatric nephrology care; outlines the specific impact of systemic biases and racism on chronic kidney disease care and transplant outcomes; characterizes and critiques the diversity of the current pediatric nephrology workforce; and aims to provide strategies to acknowledge and dismantle bias, address barriers to care, improve diversity in recruitment, and strengthen the pediatric nephrology community. By recognizing historical and current realities and limitations, we can move forward with strategies to address racism and bias in our field and clinical practices, thereby cultivating inclusive training and practice environments.

Social needs screening and referral in pediatric primary care clinics: a multiple case study

Background

Unmet social risks such as housing, food insecurity and safety concerns are associated with adverse health outcomes in adults and children. Experimentation with social needs screening in primary care is currently underway throughout the United States. Pediatric primary care practices are well-positioned to amplify the effects of social needs screening and referral programs because all members of the household have the potential to benefit from connection to needed social services; however, more research is needed to determine effective implementation strategies.

Methods

To describe common implementation barriers and facilitators, we conducted 48 in-depth qualitative interviews with leadership, providers and staff between November 2018 and June 2019 as part of a multiple case study of social needs screening and referral programs based out of four pediatric ambulatory care clinics in New York City. Interviews were recorded, transcribed and coded using a protocol-driven, template-based rapid analysis approach designed for pragmatic health services research. In addition to analyzing content for our study, we delivered timely findings to each site individually in order to facilitate quality improvement changes in close-to-real time.

Results

Effective implementation strategies included tailoring screening tools to meet the needs of families seen at the clinic and reflect the resources available in the community, hiring dedicated staff to manage the program, building strong and lasting partnerships with community-based organizations, establishing shared communication methods between partners, and utilizing technology for efficient tracking of screening data. Respondents were enthusiastic about the value of their programs and the impact on families, but remained concerned about long-term sustainability after the grant period.

Conclusion

Implementation of social needs screening and referral interventions is dependent on contextual factors including the nature of family needs and the availability of intraorganizational and community resources to address those needs. Additional research is needed to prospectively test promising implementation strategies that were found to be effective across sites in this study. Sustainability of programs is challenging, and future research should also explore measurable outcomes and payment structures to support such interventions in pediatric settings, as well as aim to better understand caregiver perspectives to improve engagement.

Concordance in Adolescent and Caregiver Report of Social Determinants of Health

INTRODUCTION

Screening youth for negative social determinants of health is a widespread practice across healthcare settings in the U.S., with such systems almost exclusively relying on caregiver reports. Little work has sought to identify the social determinants of health adolescents identify as having the largest influence on their health and well-being or the extent to which adolescents agree with their caregiver. This study sought to (1) identify the most prevalent and influential negative social determinants of health, according to adolescent reports, and (2) assess concordance between adolescent and caregiver reports of social determinants of health.

METHODS

In Fall 2021, the study team conducted a cross-sectional, observational study within a predominately Latinx urban high school. The team invited all students and their caregivers to participate, resulting in 520 adolescent and 66 caregiver respondents (73% and 9% response rates, respectively). Data analyses occurred in 2022.

RESULTS

The most frequent adolescent-reported negative social determinants of health was stress (67%), followed by financial hardship (27%). The negative social determinant of health with the highest ranking of preventing adolescents from living their best and healthiest lives was depression, followed by isolation and stress. Concordance between caregiver and adolescent report of negative social determinants of health was very low across all negative social determinants of health (Krippendorf's α= -0.08 to 0.21). Caregivers under-reported adolescents' social and mental health needs, whereas adolescents under-reported material needs.

CONCLUSIONS

A hybrid informant approach may be a best practice for social determinants of health screening among adolescents, whereby caregivers and adolescents report material needs, and adolescents report social and mental health needs. Future work should evaluate the concordance between adolescent and caregiver social determinants of health reports in other settings.

Early Childhood Referrals by HealthySteps and Community Health Workers

This study explored how a community health worker (CHW) within a primary care team with a HealthySteps (HS) Specialist impacted referrals to social determinant of health resources for families with children aged birth to 5 years. Medical charts with documentation of HS comprehensive services between January and June 2018 were reviewed at 3 primary care clinics: 2 with an HS Specialist (HSS Only) and 1 with an HS Specialist and CHW (HSS + CHW). Eighty-six referrals were identified, 78 of which had documented outcomes. Outcomes were categorized as successful, unsuccessful, and not documented. The HSS + CHW group had a higher rate of successful referrals (96%) than the HSS Only group (74%). Statistical analysis (χ² = 8.37, P = .004) revealed a significant association between the referral outcome and having a CHW on a primary care team with an HS Specialist. Therefore, primary care practices should consider adapting their HS model to include CHWs.

Screening Families in Primary Care for Social and Economic Needs: Patients' Urgency and Activation for Social Care Navigation

INTRODUCTION

Social determinants of health (SDoH) screening and intervention in primary care aim to alleviate adverse influences on health, but its efficacy may be diluted when offered supports are not well matched to families' desire for such services. The purpose of this prospective cohort study was to provide guidance to social care navigation teams regarding which families would be most likely to make use of services.

METHODS

Analysis of registry data collected in April 1-September 30, 2021 from a social care navigation program embedded in a medical home was conducted. Multivariable regression models explored (1) whether family-reported urgency of needs, number of needs, and/or specific types of needs predicted completing program intake and (2) whether the degree of family activation regarding social needs predicted subsequent interactions with the navigation team.

RESULTS

Of the 1,483 families reporting any social care needs (38% of all screens completed, mean of 2.5 needs per screen), 31% indicated that their needs were urgent. Accounting for program factors and the number and type of needs reported, families whose needs were urgent were more likely to complete intake (OR=1.34; 95% CI=1.01, 1.82; p=0.04) and remain engaged with the program over time (OR=2.25; 95% CI=1.62, 3.12; p<0.01). Those who were self-advocates were substantially less likely to desire follow-up or stay engaged (OR=0.40; 95% CI=0.17, 0.93; p<0.01).

CONCLUSIONS

Family-reported urgency of needs and activation for social care assistance predicted engagement with the navigation team. SDoH interventions should prioritize outreach to those families expressing an interest in help with any of their identified needs.

Social Emergency Medicine: Capitalizing on the Pediatric Emergency Department Visit to Screen and Connect Patients and Families to Community Resources

OBJECTIVE

To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources.

METHODS

Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs.

RESULTS

Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others.

CONCLUSIONS

The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.

Pediatric emergency department organization and social care practices among U.S. fellowship programs

Background

Social care has become increasingly relevant to the emergency physician and includes activities that address health-related social risk and social needs. The literature has consistently documented substantial health care provider challenges in incorporating social care into routine practice. Yet, interventions on the health care organizational level hold promise to bring about more widespread, sustainable impact.

Methods

This study was a subanalysis of the 2021 National Social Care Practices Survey data set among pediatric emergency medicine (PEM) program directors (PDs) and fellows. The purpose was to investigate the association between health care organizational factors and PEM physician social care practices and perceptions among PEM PDs and fellows. We performed binary and ordinal logistic regressions of organizational factors and five specific PEM physician social care perspective and practice outcomes.

Results

The sample population included 153 physicians-44 PDs (49% response rate) and 109 fellows (28%). PDs and fellows with access to a social care systematic workflow in their pediatric emergency department (PED) had higher odds of comfort assessing social risk (odds ratio [OR] 2.1%, 95% confidence interval [CI] 1.1-4.0), valuation of social care (OR 3.2, 95% CI 1.3-7.9), preparedness to assist families (OR 2.4, 95% CI 1.1-5.2), screening tendency (OR 2.2, 95% CI 1.1-4.5), and ability to refer to community resources (OR 2.3, 95% CI 1.2-4.6). A similarly directed, but less pronounced pattern was noted with access to a community resource database for referrals and 24-h access to a social worker in the PED.

Conclusions

PED organizational factors-particularly access to a social care systematic workflow-appear positively associated with PEM physician practices and perceptions of social care delivery. Further research is under way to advance understanding of PEM training factors in social care.

A Framework for Cross-Sector Partnerships to Address Childhood Adversity and Improve Life Course Health

Childhood adversity and its structural causes drive lifelong and intergenerational inequities in health and well-being. Health care systems increasingly understand the influence of childhood adversity on health outcomes but cannot treat these deep and complex issues alone. Cross-sector partnerships, which integrate health care, food support, legal, housing, and financial services among others, are becoming increasingly recognized as effective approaches address health inequities. What principles should guide the design of cross-sector partnerships that address childhood adversity and promote Life Course Health Development (LCHD)? The complex effects of childhood adversity on health development are explained by LCHD concepts, which serve as the foundation for a cross-sector partnership that optimizes lifelong health. We review the evolution of cross-sector partnerships in health care to inform the development of an LCHD-informed partnership framework geared to address childhood adversity and LCHD. This framework outlines guiding principles to direct partnerships toward life course-oriented action: (1) proactive, developmental, and longitudinal investment; (2) integration and codesign of care networks; (3) collective, community and systemic impact; and (4) equity in praxis and outcomes. Additionally, the framework articulates foundational structures necessary for implementation: (1) a shared cross-sector theory of change; (2) relational structures enabling shared leadership, trust, and learning; (3) linked data and communication platforms; and (4) alternative funding models for shared savings and prospective investment. The LCHD-informed cross-sector partnership framework presented here can be a guide for the design and implementation of cross-sector partnerships that effectively address childhood adversity and advance health equity through individual-, family-, community-, and system-level intervention.

Clinical Stakeholder Perspectives on Pediatric Inpatient Screening for Social Needs

OBJECTIVES

Social determinants of health are major drivers of health outcomes and quality of life. While several social needs screening tools have been created for use in primary care settings, the best procedures to incorporate these tools into hospital workflow remain unclear. This study aimed to elicit clinical stakeholder perspectives on proposed screening for social needs during pediatric hospitalizations, with particular focus on informing implementation strategies.

METHODS

We conducted 23 semistructured interviews with pediatric clinical stakeholders (physicians, nurses, social workers, and case managers) at 1 tertiary and 2 community hospitals between July 2020 and January 2021, on topics including social needs screening practices, benefits and challenges to inpatient screening, and optimal screening and referral processes within hospital workflow. Interviews were recorded, professionally transcribed, and analyzed thematically.

RESULTS

Participants ranged in age from 25 to 62 years, with nearly half working in community hospitals. Regarding inpatient social needs screening, themes emerged about benefits, including enabling clinicians to identify vulnerable patients/moments, and providing clinicians with comprehensive understanding of social context; barriers, including prioritization of medical needs, lack of clinician education surrounding screening, and lack of pre-established relationships; facilitators, including duration of time spent with families, and multidisciplinary clinicians; screening process preferences, including verbal screening, and integration into pre-existing systems; and referral process preferences, including resource provision with family empowerment, and care transition to outpatient clinicians.

CONCLUSIONS

Clinical stakeholders identified multiple barriers, facilitators, and process preferences for pediatric inpatient social needs screening, which may inform the future development of feasible and sustainable implementation strategies.

Social care practices and perspectives among U.S. pediatric emergency medicine fellowship programs

BACKGROUND

The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine.

METHODS

The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions.

RESULTS

A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development.

CONCLUSIONS

PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus.

Assessing and Addressing Social Determinants of Health Among Children and Youth With Special Health Care Needs

Over several decades, a field of research has emerged to examine social and environmental factors that contribute to health inequities among children and youth with special healthcare needs (CYSHCN), with the goal of reducing inequities through identifying and mitigating these social determinants of health (SDH). The Children and Youth with Special Healthcare Needs National Research Network (CYSHCNet) national research agenda development process, described in a companion article, recognized SDH, as experienced by CYSHCN, and the effects on health inequity and child and family outcomes as a high priority area. Important gaps named included which strategies best identify and mitigate the effects of negative SDH and which outcomes are most meaningful to families receiving SDH-focused interventions. In this area, the highest priority questions were the following: 1) How can SDH be routinely addressed in the course of care for CYSHCN? 2) Which interventions most effectively integrate SDH to improve child and family outcomes? Here, we discuss the impact of SDH on CYSHCN, efforts to screen for and intervene upon SDH in this population, and gaps in the current research on SDH specific to CYSHCN. We make several recommendations for research studies that will move the field forward. This work should achieve a greater understanding of patterns and impacts of SDH experienced by CYSHCN. It will also contribute to optimizing identification of SDH and improving interventions to achieve equity in health outcomes identified by patients and families as important to them.

Screening for Adverse Childhood Experiences in Children: A Systematic Review

CONTEXT

Adverse childhood experiences (ACEs) are associated with increased risk of poor mental health outcomes. Although there is interest in screening for ACEs for early identification and intervention, it is not known whether screening improves outcomes for children.

OBJECTIVE

To systematically review whether screening for ACEs in children leads to an increase in (1) identification of ACEs, (2) referrals to services, (3) increased uptake of services, and (4) improved mental health outcomes for children and parents.

DATA SOURCES

Ovid Medline, PsycINFO, CINAHL, and Center for Clinical and Translational Research electronic databases were searched between 2009 and 2021.

STUDY SELECTION

Studies were included if researchers screened for current ACEs in children aged 0 to 12 years and they had a control comparison.

DATA EXTRACTION

Information was extracted, including study characteristics, sample demographics, screening tool characteristics, referral rates to services, uptake rates, and mental health outcomes.

RESULTS

A total of 5816 articles were screened, with 4 articles meeting inclusion criteria. Screening for ACEs increases identification of adversity and may increase referrals to services. There are limited data about whether this leads to an increase in referral uptake by families. There are no reported data addressing mental health outcomes.

LIMITATIONS

There are few published control trials of moderate quality.

CONCLUSIONS

There is limited evidence that screening for ACEs improves identification of childhood adversity and may improve referrals. If we are to realize the hypothesized benefits of ACEs screening on child and parent mental health, it is essential to understand the barriers for families taking up referrals.

Addressing social determinants of health in pediatric health systems: balancing mission and financial sustainability

PURPOSE OF REVIEW

With increasing recognition of the impact of poverty, racism and other social factors on child health, many pediatric health systems are undertaking interventions to address Social Determinants of Health (SDoH). This review summarizes these initiatives and recent developments in state and federal health policy impacting funding for these efforts.

RECENT FINDINGS

Although the evidence defining optimal approaches to identifying and mitigating SDoH in children is still evolving, pediatric health systems are making significant investments in different initiatives to address SDoH. With limited reimbursement available through traditional payment streams, pediatric health systems and Accountable Care Organizations are looking to value-based payments to help fund these interventions. Federal and state policy changes, including use of Medicaid funds for nonmedical interventions and introduction of the Accountable Health Communities model to pediatrics, offer additional funding sources to address SDoH.

SUMMARY

Initiatives among mission-driven pediatric health systems to address SDoH are increasingly common despite funding challenges. Value-based payments, expansion of Medicaid funding resulting from policy changes and delivery system reform, along with health system philanthropy and operating revenues, will all be needed to meet mission-based goals of addressing SDoH while supporting financial sustainability.

Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists

Objectives: To determine the psychosocial needs screening and intervention practices of obstetrician-gynecologists (OBGYNs) and elucidate characteristics associated with screening and resource availability. Methods: We administered a cross-sectional paper and online survey to 6288 U.S. office-based OBGYNs from March 18 to September 1, 2020, inquiring about screening and intervention practices for intimate partner violence, depression, housing, and transportation. We analyzed associations between demographic/practice characteristics and screening/having resources for all four needs. Results: 1210 OBGYNs completed the survey. One hundred ninety-five OBGYNs (16%) reported their practices screened all patients for all four needs. Having resources to address all four needs (prevalence ratio [PR] = 4.39, 95% confidence interval [CI] = 3.04-6.34), working in health centers/clinics (PR = 2.22, 95% CI = 1.43-3.45), and seeing ≥50% Medicaid patients (PR = 1.62, 95% CI = 1.02-2.58) were associated with screening for all four needs. One hundred sixty-eight OBGYNs (14%) reported their practices had resources onsite to address all four needs. Working in health centers/clinics (PR = 3.99, 95% CI = 2.56-6.22), large practices (PR = 3.37, 95% CI = 1.63-6.95), Medicaid expansion states (PR = 2.60, 95% CI = 1.45-4.65), and practices with >11% uninsured patients (PR 2.30, 95% CI = 1.31-4.04) were associated with having resources onsite for all four needs. Conclusion: Most OBGYN practices appeared underresourced to address psychosocial needs within clinical care. Innovative financial models or collaborative care models may help incentivize this work.

Provider Perspectives on Screening for Social Determinants of Health in Pediatric Settings: A Qualitative Study

INTRODUCTION

Pediatric settings often screen children and/or caregivers for social determinants of health (SDH) needs. Although SDH awareness rose with COVID, questions remain regarding best practices for SDH screening in pediatric settings.

METHOD

We assessed pediatric providers' perspectives on integrating SDH screening into patient care. Semistructured interviews were conducted with providers (n = 13) from 10 clinics. Interviews were transcribed, and themes were analyzed using the constant comparative method.

RESULTS

Themes highlighted providers' awareness of structural limitations to address social needs identified by screening; implementation concerns; the unique role of pediatric providers for child health and well-being; provider comfort with assessing patients' social needs; patient considerations; the importance of relational health between pediatric providers and families, and between providers and community supports for effective screening; and unintended consequences.

DISCUSSION

Pediatric providers endorse the need for SDH screening, but barriers in pediatric settings may hamper the process and reduce efficacy.

Clinical Approaches to Reducing Material Hardship Due to Poverty: Social Risks/Needs Identification and Interventions

The field of pediatrics has pioneered approaches to mitigating poverty's harmful effects on children's health and development. Clinical interventions for systematically addressing material hardships due to poverty within the context of pediatric care delivery, however, are still in their infancy. Since the American Academy of Pediatrics published its policy statement on Child Health and Poverty in the United States in 2016, interest has surged in the development and implementation of care models that systematically identify and address social risks and/or social needs. This article explores this major shift in interest, research, and investment in such interventions within pediatric care. We provide an overview of current screening and referral models for addressing poverty-related social factors and explore the strengths and weaknesses of these varied approaches. We summarize the current evidence supporting such clinical approaches, and comment on the importance of multi-sectoral partnerships in addressing families' and communities' needs. Lastly, we propose future directions for research and pediatric practice that may enhance the uptake of social risks/needs interventions and bolster the evidence of their effectiveness. Though clinical approaches for addressing material hardship may be limited by an insufficient social safety net and other barriers, interventions to identify and address families' social risks and social needs have the potential to combat poverty's impact on children and advance health equity.

Transforming Well-Child Care to Meet the Needs of Families at the Intersection of Racism and Poverty

Racism and poverty are intertwined throughout American society as a result of historic and current systemic oppression based on class and race. As the processes of pediatric preventive care, or well-child care, have evolved to better acknowledge and address health disparities due to racism and poverty, the structures of care have remained mostly stagnant. To cultivate long-term health and wellness of Black and Brown children, we must adopt an explicitly antiracist structure for well-child care. The pediatric medical home model is touted as the gold standard for addressing a host of health, developmental, and social needs for children and their families. However, the medical home model has not resulted in more equitable care for Black and Brown families living in poverty; there are ample data to demonstrate that these families often do not receive care that aligns with the principles of the medical home. This inequity may be most salient in the context of well-child care, as our preventive care services in pediatrics have the potential to impact population health. To appropriately address the vast array of preventive care needs of families living at the intersection of racism and poverty, a structural redesign of preventive care in the pediatric medical home is needed. In this paper, we propose a re-imagined framework for the structure of well-child care, with a focus on care for children in families living at the intersection of racism and poverty. This framework includes a team-based approach to care in which families build trusting primary care relationships with providers, as well as nonclinical members of a care team who have shared lived experiences with the community being served, and relies on primary care connections with community organizations that support the preventive health, social health, and emotional health needs of families of young children. Without a structural redesign of preventive care in the pediatric medical home, stand-alone revisions or expansions to processes of care cannot appropriately address the effects of racism and poverty on child preventive health outcomes.

Community Health Worker Intervention to Address Social Determinants of Health for Children Hospitalized With Asthma

BACKGROUND

Social determinants of health (SDOH) contribute to racial disparities in asthma outcomes. Community health worker (CHW) programs represent a promising way to screen for SDOH and connect patients to resources, but the impact of CHW programs in the inpatient pediatric setting has been examined in few studies. In this study, we aimed to evaluate a CHW program for children hospitalized with asthma in a predominantly Hispanic community by examining rates of SDOH and social resource navigation.

METHODS

This pilot study involved a CHW intervention to improve pediatric asthma care. Patients were included if they were hospitalized with asthma over an 18-month period and enrolled in the CHW program during their hospitalization. In an intake interview, CHWs screened caregivers for SDOH and provided tailored social resource navigation. Descriptive statistics were used to assess rates of social risk factors and social resource navigation.

RESULTS

Eighty patients underwent SDOH screening. The majority of patients were Hispanic (81.3%, n = 65). Half of caregivers reported food or housing insecurity over the past 12 months (50.0%, n = 40), and most reported inadequate housing conditions (63.8%, n = 51). CHWs coordinated social resources for the majority of families (98.8%, n = 79), with the most common being food resources (42.5%, n = 34), housing resources (82.5%, n = 66), and appointment navigation (41.3%, n = 33).

CONCLUSIONS

CHWs identified a high burden of unmet social needs and provided associated social resource navigation in a largely Hispanic pediatric population hospitalized for asthma. CHW programs have potential to improve asthma outcomes by linking high-risk patients with social resources.

Pediatric primary care and subspecialist providers' comfort, attitudes and practices screening and referring for social determinants of health

BACKGROUND

Early detection and management of poverty-related disorders is a recommended pediatric practice; however, little is known about variations of practice between pediatric primary care physicians and subspecialists. The objectives of this study were to assess (1) provider perceptions and attitudes toward caring for low-income children in an urban academic medical center, and (2) variations between primary care physicians and subspecialists in social and financial needs screening and referral practices for low-income children.

DESIGN/METHODS

Primary care providers (pediatric and family medicine) and subspecialists providing direct patient care in an urban academic medical center (response rate = 24 %, n = 85/356) completed a 24-item survey (adapted with permission from the AAP Periodic Survey of Fellows No.90) assessing feasibility and comfort screening and addressing social and financial needs, rates of screening for financial hardship, and referrals to local resources. Chi-square tests were performed.

RESULTS

Among respondents, 88 % (75/85) reported comfort caring for low-income children, while 28 % (24/85) reported comfort inquiring about social and financial needs and 34 % (29/85) referring to community resources. Primary care providers more commonly than subspecialists screened for childcare (80 % vs. 59 %, p = 0.04), parental: employment (84 % vs. 59 %, p = 0.01), education (40 % vs. 17 %, p = 0.02) and mental health (86 % vs. 46 %, p = 0.0001), and less commonly screened for transportation (47 % vs. 73 %, p = 0.01). Primary care providers more commonly referred for public health insurance (74 % vs. 39 %, p = 0.001), public food assistance (30 % vs. 12 %, p = 0.04), and adult mental health services (65 % vs. 44 %, p < 0.05).

CONCLUSIONS

In an urban academic institution serving a population with high poverty rates, pediatric providers feel comfortable providing medical care for low-income children but lack comfort screening and addressing SDH. Though most feel it is their job to refer to resources, less than half felt it was feasible to screen for or address financial needs. Pediatric primary care providers report higher rates of screening and referring than subspecialists. Understanding variations in practice and perceptions among primary care providers and subspecialists may aid in creating interventions to increase screening and referral rates.

Prevalence of Social Risks on Inpatient Screening and Their Impact on Pediatric Care Use

OBJECTIVES

Screening for social determinants of health in the inpatient setting is uncommon. However, social risk factors documented in billing and electronic medical record data are associated with increased pediatric care use. We sought to describe (1) the epidemiology of social risks and referral acceptance and (2) association between social risks identified through routine inpatient screening and care use.

METHODS

Parents of children ages 0 to 18 admitted to a general pediatric floor at an academic children's hospital completed a psychosocial screening survey from October 2017 to June 2019. The survey covered the following domains: finances, housing, food security, medications, and benefits. Patient characteristics and care use outcomes were abstracted from the electronic medical record and compared by using Pearson's χ² or the Wilcoxon rank test and logistic regression analyses.

RESULTS

Of 374 screened families, 141 (38%) had a positive screen result, of whom 78 (55%) reported >1 need and 64 (45%) accepted a community resource. In bivariate analyses, patients with a positive screen result had higher 30-day readmission (10% vs 5%; P = .05), lower median household income ($62 321 vs $71 460; P < .01), lower parental education (P < .01), public insurance (57% vs 43%; P < .01), lived in a 1-parent household (30 vs 12%; P < .01), and had a complex chronic condition (35% vs 23%; P = .01) compared with those with a negative screen result. There was no difference in care reuse by screening status in adjusted analyses.

CONCLUSIONS

Social risks are common in the pediatric inpatient setting. Children with medical complexity offer a good target for initial screening efforts.

Factors Related to Providers Screening Children for Behavioral Health Risks in Primary Care Settings

PURPOSE

To provide information from a large sample of pediatric and family medicine primary care providers on practices in screening children for behavioral health risks.

DESIGN AND METHODS

Participants were a sample of physicians (n=319) and nurse practitioners (n=292) from across the U.S. who completed a confidential online survey about screening practices through a computer-assisted self-interview.

RESULTS

Almost all respondents (89%) reported screening children for depression/anxiety and behavior problems. Child substance use (82%), family social support (74%), significant household changes (73%), bullying (72%), child abuse (62%) and domestic violence (52%) were also asked about regularly, although with high rates of informal screening methods. Caregiver mental health (49%), caregiver substance use (35%), family financial strain (33%) and transportation difficulties (27%) were screened less frequently. Screening was associated with higher rates of referral for risk-related problems, and was more likely when providers reported greater confidence providing support to clients, perceived community resource availability as higher, and worked in systems with integrated primary care and behavioral health.

CONCLUSIONS

Findings suggest a great amount of diversity in how providers screen for behavioral health risks. There is reluctance to screen when options for addressing the problems are seen as limited. Research is needed to better guide healthcare providers in determining the right context and methods for screening social risks.

PRACTICE IMPLICATIONS

Protocols for screening adverse childhood events (ACES) and other social risk factors should be accompanied by adequate training and efforts to improve community resource and support networks.