Use of colocated multidisciplinary services to address family psychosocial needs at an urban pediatric primary care clinic

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.

Characterization of Social Risk Factors Among Newborns Seen at an Urban Pediatric Primary Care Predictive of Appointment Nonattendance During the First 6 Months of Life

Purpose: Appointment attendance is critical in monitoring health and well-being of children. Low income Medicaid-insured families with newborns often experience social risks that may affect attendance. This project sought to characterize social risk factors present at first newborn visits predictive of future appointment nonattendance.

Methods: Retrospective cohort study of minority and Medicaid-insured population at St. Christopher's Hospital for Children using a standardized social risk screener administered at first newborn visits as part of routine clinical care. In total, 720 survey responses between December 2016 and June 2017 were correlated with electronic health record-derived sociodemographic and appointment attendance data in the first 6 months of life. Nonattendance included missed and canceled appointments. Caregiver-reported social risk factors were included as covariates in linear regressions predicting proportion nonattendance outcomes.

Results: Newborn caregivers identified many social risk factors including mental health diagnoses (14%), lack of child care support (45%), and food insecurity (9%). Approximately 74% had nonattendance with 41% missing or canceling a quarter or more appointments. Number of siblings (p<0.01) and maternal age (p<0.01) were most predictive for nonattendance, respectively. Other social risks were not significant except for maternal mental health (p=0.01) among those identifying number of risk factors above cohort average (16%).

Conclusion: Screening of newborns at first medical visits can be used to characterize social risks. Most social risk factors at first visits were not strongly predictive of nonattendance, although our results suggested associations between non-attendance and maternal demographics, mental health and household makeup.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

A Primary Care Intervention to Prevent Repeat Pregnancy Among Teen Mothers

INTRODUCTION

The purpose of this study is to determine the effectiveness of a patient-centered medical home intervention for teen parent families in reducing rates of unintended repeat pregnancy in the first 2 years postpartum.

METHODS

A prospective quasi-experimental evaluation was conducted with 98 African American, low-income, teen mother (aged <20 years) participants who received either the intervention or standard pediatric primary care. All participants completed structured interviews at baseline (child aged 2 months) and at follow-ups 12 and 24 months later. Data were collected from 2011 to 2015. Participants reported number of pregnancies, contraception used at last intercourse, depressive symptoms, and romantic status of the relationship with the baby's father. Analyses were conducted from 2015 to 2017.

RESULTS

Logistic regression showed that mothers in the intervention group were half as likely as mothers who received standard pediatric primary care to have a repeat pregnancy within 2 years (OR=0.55, p=0.16). The main effect of the intervention on lower rates of repeat pregnancy was mediated by higher rates of contraceptive use. Depression was associated with higher odds of repeat pregnancy, but did not appear to mediate the intervention effect.

CONCLUSIONS

This comprehensive and integrated model of care for teen parents may be an effective method to prevent rapid repeat pregnancies in this vulnerable population.

Desirability of Clinic-Based Financial Services in Urban Pediatric Primary Care

OBJECTIVES

To determine the desirability of integrating financial services in pediatric primary care among caregivers and older adolescents.

STUDY DESIGN

We conducted a cross-sectional study among caregivers and late adolescents 18 years and older attending an urban, pediatric primary care clinic.

RESULTS

The 221 participants had a mean age of 32.1 years, with 28% of the sample aged 18-25 years. The majority were African American (90.1%), female (83.3%), and single parents (55.1%). More than one-third of the participants (35.8%) reported no household earned income, and 26.7% had a yearly household total income of <$12,000. More than one-half (61.5%) reported financial stress in general, and 67.9% believed that the clinic should provide financial services, including financial education and job workshops. A greater proportion of those who desired clinic-based services were African American (94.7% vs 75%; P < .001) and had a low or middle subjective social status (95.7% vs 83.7%; P = .01).

CONCLUSIONS

Clinic-based financial services are desired by caregivers and late adolescents in an urban pediatric primary care practice. Prospective studies are needed to assess the long-term impact of integrated services on childhood poverty and family well-being.

Test of a Conceptual Model to Explain Television Exposure of Head Start Children

Excessive television (TV) viewing by children can lead to negative health and developmental outcomes. Using structural equation modeling, this study tests a conceptual model to understand social and familial factors associated with TV exposure among a sample of 767 Head Start families with children between the ages of 3 and 5 years. Fit statistics suggested that the overall model provided an acceptable fit to the observed data. Specifically, significant structural paths suggest that parents' social support affects child TV exposure. Additionally, lower levels of social support were associated with significantly greater parental stress, which also predicted child TV exposure. Findings suggest that physicians and other team members of the patient-centered medical home may benefit from broad-based interventions that address familial factors to combat excess TV exposure among children. Urging parents to turn off the TV could fail to address the underlying causes of child TV exposure.

Collaborative youth mental health service users, immigration, poverty, and family environment

BACKGROUND

This article examines the association between immigration, poverty and family environment, and the emotional and behavioral problems reported by youth and their family receiving mental health (MH) services within a collaborative care model in a multiethnic neighborhood.

METHOD

Participants in this study were 140 parent-child dyads that are part of an ongoing longitudinal project looking at the association between individual, familial, social and organizational factors, and outcomes of youth receiving MH services in local health and social service organizations in the Montreal area. Measures included in this study were collected at the initial phase of the longitudinal project (Time 0). Parents completed a sociodemographic questionnaire and the Family Environment Scale (FES), and both parents and children completed the Strength and Difficulties questionnaire (SDQ).

RESULTS

Results suggest that the family environment, especially family conflicts, has a significant role in the MH problems of children seeking help in collaborative MH services. In this specific population, results also show a trend, but not a statistically significant association, between poverty or immigration and emotional and behavioral problems. They suggest as well that boys show more MH problems, although this could be a contamination effect (parents' perspective).

CONCLUSIONS

The results support the importance of interventions that not only target the child symptomatology but also address family dynamics, especially conflicts. Collaborative care models may be particularly well suited to allow for a coherent consideration of family environmental factors in youth mental health and to support primary care settings in addressing these issues.

Integrating Maternal Mental Health Care in the Pediatric Medical Home: Treatment Engagement and Child Outcomes

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

Off to the Right Start: Well-Child Visit Attendance Among Health Center Users

INTRODUCTION

This study examines correlates of past-year well-child visit attendance, reasons for choosing to receive care at a health center, and patient experience among pediatric federally qualified health center users.

METHOD

This observational study used cross-sectional 2009 Health Center Patient Survey data. Descriptive statistics, bivariate analysis, and multivariable models were utilized.

RESULTS

This study found that 83.0% of children who visited a health center in the past year had a well-child visit in the past year and 88.5% had a usual source of care, with no disparities based on race/ethnicity or insurance status. A usual source of care, especially a health center, enhanced well-child visit attendance. The top reasons for seeking care at a health center include convenience (31.6%), quality (24.5%), accessibility (17.7%), and co-located nonmedical services (11.5%).

DISCUSSION

Well-child visit attendance is high but there is room for improvement, particularly among patients who lack a usual source of care.

Poverty and Child Health in the United States

Almost half of young children in the United States live in poverty or near poverty. The American Academy of Pediatrics is committed to reducing and ultimately eliminating child poverty in the United States. Poverty and related social determinants of health can lead to adverse health outcomes in childhood and across the life course, negatively affecting physical health, socioemotional development, and educational achievement. The American Academy of Pediatrics advocates for programs and policies that have been shown to improve the quality of life and health outcomes for children and families living in poverty. With an awareness and understanding of the effects of poverty on children, pediatricians and other pediatric health practitioners in a family-centered medical home can assess the financial stability of families, link families to resources, and coordinate care with community partners. Further research, advocacy, and continuing education will improve the ability of pediatricians to address the social determinants of health when caring for children who live in poverty. Accompanying this policy statement is a technical report that describes current knowledge on child poverty and the mechanisms by which poverty influences the health and well-being of children.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Childhood Poverty: Understanding and Preventing the Adverse Impacts of a Most-Prevalent Risk to Pediatric Health and Well-Being

Poor children are at greater risk for worse health, less productivity, and harms to well-being that extend into adulthood and subsequent generations. Timing and duration of poverty matter and influence life course outcomes, especially for education, health, and lifetime productivity. This article focuses on interventions by policy advocacy and the pediatric health system, and protection of the health and well-being of families in economic hardship from disadvantages and trauma wrought by poverty. A framework is presented for child poverty prevention and its consequences for lifelong health and success on a national scale.

Linking community resources in diabetes care: a role for technology?

Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as "assets"). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care.