Social Risk Screening for Pediatric Inpatients

Pediatric Hospital Admissions with Concern for Neglect: Correlations Between Neglect Types and Other Clinical and Environmental Risk Factors

OBJECTIVE

Child neglect is a public health concern with negative consequences that impact children, families, and society. While neglect is involved with many pediatric hospitalizations, few studies explore characteristics associated with neglect types, social needs, and post-discharge care.

METHODS

Data on neglect type, sociodemographics, social needs, inpatient consultations, and post-discharge care were collected from the electronic medical record for children aged 0-5 years who were hospitalized with concern for neglect during 2016-2020. Frequencies and percentages were calculated to determine sample characteristics. The Chi-square Test for Independence was used to evaluate associations between neglect type and other variables.

RESULTS

The most common neglect types were inadequate nutrition (40%), inability to provide basic care (37%), intrauterine substance exposure (25%), combined types (23%), and inadequate medical care (10%). Common characteristics among neglect types included age less than 1 year, male sex, Hispanic ethnicity, public insurance, past involvement with Child Protective Services, and inpatient consultation services (social work, physical therapy, and occupational therapy), and post-discharge recommendations (primary care, physical therapy, and regional center). Neglect type groups varied by child medical history, social needs, and discharge recommendations. Statistically significant associations supported differences per neglect type.

CONCLUSIONS

Our findings highlight five specific types of neglect seen in an impoverished and ethnically diverse geographic region. Post-discharge care needs should focus on removing social barriers and optimizing resources, in particular mental health, to mitigate the risk of continued neglect. Future studies should focus on prevention strategies, tailored interventions, and improved resource allocations per neglect type and discharge location.

Screening for adverse social conditions in child healthcare settings: protocol for a systematic review

INTRODUCTION

Adverse social conditions affect children's development and health outcomes from preconception throughout their life course. Early identification of adverse conditions is essential for early support of children and their families. Healthcare contacts with children provide a unique opportunity to screen for adverse social conditions and to take preventive action to identify and address emerging, potentially harmful or accumulating social problems. The aim of our study is to identify and describe available screening tools in outpatient and inpatient healthcare settings that capture social conditions that may affect children's development, health or well-being.

METHODS AND ANALYSIS

We will conduct a systematic review and will report the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. A systematic search of three databases (PubMed (Ovid), PsycInfo (EBSCOhost) and Web of Science Core Collection (Clarivate)) for English-language and German-language articles from 2014 to date will be conducted. We will include peer-reviewed articles that develop, describe, test or use an instrument to screen children for multiple social conditions in paediatric clinics or other outpatient or inpatient child healthcare settings. Key study characteristics and information on screening tools will be extracted and presented in structured tables to summarise the available evidence. We will assess the methodological quality of the instruments with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as we will not be collecting any personal data. Dissemination will consist of publications, presentations, and other knowledge translation activities.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients.

METHODS

We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation.

RESULTS

The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults.

CONCLUSIONS

Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Development and content validation of a questionnaire to assess the social determinants of mental health in clinical practice

Introduction

There is growing consensus that consideration of the Social Determinants of Mental Health should be at the centre of mental health care provision. To facilitate this, a validated means to assess mental health service users' social contextual information is arguably needed. We therefore developed a questionnaire to assess the Social Determinants of Mental Health in clinical practice.

Methods

Our guideline-informed development consisted of three steps; i) construct and purpose definition, ii) initial item generation based on the literature, similar questionnaires, and a selection of the ICD-10, iii) evaluation, revision, and content validation of the questionnaire. Initially we developed 249 items that were reduced, revised, and validated in several stages to 73 items. Content validation of the questionnaire was achieved through surveys and focus groups including mental health care service users and professionals.

Results

The surveys and focus groups indicated the need for a standardised assessment of adverse social factors and highlighted that the benefits of such an assessment would be a more holistic approach to identifying and addressing fundamental factors involved in the development of mental health difficulties. Importantly, this study also revealed how any assessment of the Social Determinants of Mental Health must prioritise the assessed person having a central role in the process and control over their own data. The focus groups identified contradicting recommendations regarding the most suitable context to administer the questionnaire.

Discussion

The resulting questionnaire can be considered to be theoretically robust and partially validated. Future research is discussed.

Pediatric psychoSocial Risk Index: Factor Analysis and Item Reduction Study

OBJECTIVES

The Pediatric psychoSocial Risk Index (PSRI) is psychosocial risk screening instrument for health practitioners. The objective of this study was to confirm validity evidence of a truncated version of PSRI.

METHODS

PSRI was completed initially by 100 parents of children aged 0 to 18 years admitted to a tertiary hospital; 50 parents repeated the PSRI 3 days later. Analysis includes principal component analysis (PCA) to include the least number of items that explain the most variance in a shortened version of PSRI as well as confirming test-retest reliability and internal consistency of the shortened instrument.

RESULTS

PSRI originally had 86 items, 85 close-ended items were analyzed. Three items were excluded because of missing test-retest data. Item reduction resulted in truncation of 16 items; 66 items remained. A Kaiser-Mayer-Orkin test of sampling adequacy resulted in reduction of 14 items; 52 items remained. Initial PCA led to reduction of 26 items. The PCA was rerun on remaining items, resulting in reduction of 6 further items; 18 items remained. Two items with >10% missingness were removed leaving 16 items in the final PSRI. Test-retest reliability was 0.98 and mean within-person across-item reliability was 0.95. Cronbach α was 0.9. Remaining items represented 9 social risk themes: food insecurity, medical complexity, home environment, behavioral issues, financial insecurity, parenting confidence, parental mental health, social support, and unmet medical needs.

CONCLUSIONS

PSRI was reduced from 86 to 16 items with high internal consistency and reliability. PSRI demonstrates adequate validity supporting practitioners to screen families about their psychosocial risk.

Evaluating the Impact of a Pediatric Inpatient Social Care Program in a Community Hospital

OBJECTIVES

To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting.

METHODS

We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks.

RESULTS

Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5-5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]).

CONCLUSIONS

The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.

Parent Perspectives on Screening for Social Needs During Pediatric Hospitalizations

OBJECTIVES

Social determinants of health have been demonstrated to be important drivers of health outcomes and disparities. Screening for social needs has been routinely performed and shown to be beneficial in ambulatory settings, but little is known regarding parent perspectives on screening during pediatric hospitalizations. This study sought to determine parental attitudes surrounding inpatient screening and screening process preferences in the hospital setting.

METHODS

We conducted 17 semistructured interviews with English- and Spanish-speaking parents of hospitalized children at 1 tertiary and 2 community hospitals between July 2020 and February 2021, with questions probing opinions and experiences with social needs screening, comfort level with discussing social needs with hospital providers, and screening process preferences in the hospital setting. Interviews were recorded, professionally transcribed, and analyzed thematically.

RESULTS

Participants were median age 32 years, with majority female and English-speaking, and nearly one-half with children admitted to a community hospital. Emergent themes included (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient screening, and (5) importance of a family-centered approach to inpatient screening.

CONCLUSIONS

Parents reported positive perceptions regarding pediatric inpatient social needs screening importance and hospitals' ability to address social needs and identified multiple screening process preferences for the hospital setting that can inform the development of family-centered inpatient social needs screening strategies.

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.

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.

Identification of Caregiver-Reported Social Risk Factors in Hospitalized Children

OBJECTIVES

Although health systems are increasingly moving toward addressing social determinants of health, social risk screening for hospitalized children is largely unexplored. We sought to determine if inpatient screening was feasible and describe the prevalence of social risk among children and caregivers, with special attention given to children with chronic conditions.

METHODS

Caregivers of pediatric patients on the hospitalist service at a children's hospital in the Pacific Northwest completed a social risk survey in 2017. This survey was used to capture items related to caregiver demographics; socioeconomic, psychosocial, and household risks; and adverse childhood experiences (ACEs). Charts were reviewed for child demographics and medical complexity. Results were tabulated as frequency distributions, and analyses compared the association of risk factors with a child's medical complexity by using χ² tests.

RESULTS

A total of 265 out of 304 (87%) caregivers consented to participate. One in 3 families endorsed markers of financial stress (eg, difficulty paying for food, rent, or utilities). Forty percent experienced medical bill or insurance troubles. Caregiver mental health concerns were prevalent, affecting over one-third of all respondents. ACEs were also common, with 38% of children having at least 1 ACE. The presence of any ACE was more likely for children with chronic conditions than those without.

CONCLUSIONS

We found that social risk screening in the inpatient setting was feasible; social risk was uniformly common and did not disproportionately affect those with chronic diseases. Knowing the prevalence of social risk may assist in appropriate alignment of interventions tiered by social complexity.

Psychometric Evaluation of the Screener for Intensifying Community Referrals for Health

This study examined the psychometric properties of the Screener for Intensifying Community Referrals for Health (SINCERE), a 10-item, low literacy screening tool developed to elicit social needs (e.g., transportation, housing) impacting patients' ability to engage in health-related activities. Patients seeking care in a tertiary care emergency department (ED) were invited to complete the SINCERE as part of registration processes, and were asked about their desire for follow-up by a partnering service provider offering low- and no-cost community resource referrals. A total of 5,081 patients completed screenings were included in this sample. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) identified and verified one-factor structure, suggesting that the SINCERE's 10-items are homogenous and measure one construct. The reliability of Cronbach's α and McDonald's ω were 0.89. Item Response Theory (IRT) suggested the SINCERE can effectively identify patients wishing referrals, or who have social needs. Moreover, patients who had two or more social needs were those willing to receive referrals after discharge. The SINCERE is a valid and reliable tool for measuring social needs for health, and should be considered as a screening option for practice interventions seeking to address social needs.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study

OBJECTIVES

Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC.

METHODS

We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach.

RESULTS

Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions.

CONCLUSIONS

Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review

CONTEXT

Health systems increasingly are exploring implementation of standardized social risk assessments. Implementation requires screening tools both with evidence of validity and reliability (psychometric properties) and that are low cost, easy to administer, readable, and brief (pragmatic properties). These properties for social risk assessment tools are not well understood and could help guide selection of assessment tools and future research.

EVIDENCE ACQUISITION

The systematic review was conducted during 2018 and included literature from PubMed and CINAHL published between 2000 and May 18, 2018. Included studies were based in the U.S., included tools that addressed at least 2 social risk factors (economic stability, education, social and community context, healthcare access, neighborhood and physical environment, or food), and were administered in a clinical setting. Manual literature searching was used to identify empirical uses of included screening tools. Data on psychometric and pragmatic properties of each tool were abstracted.

EVIDENCE SYNTHESIS

Review of 6,838 unique citations yielded 21 unique screening tools and 60 articles demonstrating empirical uses of the included screening tools. Data on psychometric properties were sparse, and few tools reported use of gold standard measurement development methods. Review of pragmatic properties indicated that tools were generally low cost, written for low-literacy populations, and easy to administer.

CONCLUSIONS

Multiple low-cost, low literacy tools are available for social risk screening in clinical settings, but psychometric data are very limited. More research is needed on clinic-based screening tool reliability and validity as these factors should influence both adoption and utility.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Social determinants of health: the how, who, and where screenings are occurring; a systematic review

Screening for social determinants of health allows health care teams to assess and address social factors that influence one's health, mental health, and access to care. These social factors include poverty, health literacy, social support, exposure to trauma, food insecurity, and housing instability. The objective of this study was to examine what screening tools for social determinants of health are being used, in what contexts, and with what populations. Findings suggest that health literacy is the most commonly screened for, followed by trauma history, social support, food insecurity and housing across diverse contexts and populations. Results from this study can be used to inform providers of available screening tools and resources that can be readily utilized in practice.

Development of the Pediatric Social Risk Instrument Using a Structured Panel Approach

BACKGROUND

Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission.

METHODS

Using the UCLA (University of California Los Angeles)-RAND appropriateness method, consensus was reached for an instrument to identify social need in hospitalized children. A panel of 11 experts reviewed candidate indicators through 3 rounds to reach consensus. The instrument then underwent usability testing.

RESULTS

Three hundred and forty-seven indicators from the literature were sorted into 18 social risk themes. After 3 rounds, consensus was reached on 82 indicators. Six additional social risk themes were recommended by the panel, resulting in consensus for 18 additional indicators. Final refinement resulted in an instrument containing 86 indicators representing 11 social risk themes. Usability testing identified that the tool was well received by families. Final feedback was incorporated into a post-usability instrument.

CONCLUSIONS

Using the UCLA-RAND appropriateness method, a new pediatric social risk instrument was created to identify social need for hospitalized children.

Screening for social determinants of health in clinical care: moving from the margins to the mainstream

Background

Screening for the social determinants of health in clinical practice is still widely debated.

Methods

A scoping review was used to (1) explore the various screening tools that are available to identify social risk, (2) examine the impact that screening for social determinants has on health and social outcomes, and (3) identify factors that promote the uptake of screening in routine clinical care.

Results

Over the last two decades, a growing number of screening tools have been developed to help frontline health workers ask about the social determinants of health in clinical care. In addition to clinical practice guidelines that recommend screening for specific areas of social risk (e.g., violence in pregnancy), there is also a growing body of evidence exploring the use of screening or case finding for identifying multiple domains of social risk (e.g., poverty, food insecurity, violence, unemployment, and housing problems).

Conclusion

There is increasing traction within the medical field for improving social history taking and integrating more formal screening for social determinants of health within clinical practice. There is also a growing number of high-quality evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels.

An Integrative Review of Social Determinants of Health Assessment and Screening Tools Used in Pediatrics

PROBLEM

Social and physical contexts which make up social determinants of health (SDOH) have tremendous impacts on youth development, health and well-being. Despite knowledge and evidence of these impacts, few pediatric SDOH screening tools are known. The purpose of this review was to identify and evaluate available pediatric SDOH screening tools.

ELIGIBILITY CRITERIA

Articles were limited to studies in the English language, with pediatric populations, conducted in the United States, and were peer-reviewed, primary studies.

SAMPLE

Search of 3 databases (PsychInfo, CINAHL and PubMed) yielded 499 articles, 486 were excluded. Total of 13 articles were appraised and synthesized using the SDOH framework outlined by Healthy People 2020.

RESULTS

Thirteen articles relevant to the assessment of SDOH domains were evaluated. Majority of studies were limited in both the number of SDOH domains screened and the depth of screening. Tools were heterogeneous in methods used to assess SDOH risks and few were validated. Limited number of studies included youth or families in the initial development of tools.

CONCLUSIONS

Despite growing recognition across healthcare that SDOH greatly influence pediatric health risks, management and outcomes, there is a dearth of available high quality, multidimensional, comprehensive screening tools for pediatric care professionals.

IMPLICATIONS

This review emphasizes the need for the continued development of effective, comprehensive and practical tools for assessing pediatric SDOH risk factors. Pediatric nursing care includes the assessment of the youth and family context to effectively evaluate resource needs. Pediatric nurses are well poised to address this knowledge and resource gap.