A cluster randomized control trial at 8 urban community health centers, in which 336 mothers, mostly with household incomes <$20,000 and multiple unmet social needs, were enrolled. Those in the intervention arm completed the WE CARE self-report screening instrument, assessing for needs in child care, education, employment, food security, household heat, and housing. Mothers who completed WE CARE were more likely to be enrolled in a new community resource and at follow-up had greater odds of being employed, their children had greater odds of being in childcare, and the entire family had lower odds of living in a homeless shelter.
The structure and core values of the Patient Centered Medical Home (PCMH) present an opportunity to better promote health in patients of all ages by systematically addressing the social determinants of health. To facilitate the transformation of clinical care in this direction, PCMHs can adopt practices and guidelines that are already in use within the field of pediatrics. These include adhering to the American Academy of Pediatrics policy statements, screening for social determinants at all medical visits, co-locating with community-based resources to improve accessibility, integrating social determinants-focused home visits, and working to develop multidisciplinary primary care interventions.
A mixed-methods study which collected and analyzed the social determinants of health (SDOH) screening forms from 15 Boston CommunityHealth Centers serving a majority low-income (<200% FPL) population, and conducted focus group interviews on provider implementation experiences with the WE CARE SDOH screening tool. A total of 16 domains of SDOH were screened for at these sites, including material hardship, trauma/violence, and housing, with housing being the most commonly screened-for domain. The focus groups, which included physicians, nurses, and medical assistants, varied considerably on what they saw as barriers or facilitators during WE CARE screening, and frequently-addressed themes included provider perspectives and clinic workflow.
A secondary data analysis of the National Surveys of Children's Health, using a nationally representative sample of children, performed to detect trends in socioeconomic (SES) and racial/ethnic disparities in access to children's medical homes and in parental experiences with those medical homes. Subcomponents relating to parental perceptions and experiences of the medical home included having family-centered care, getting needed referrals, and having effective care coordination. Compared to 2007, from 2011 - 2012 fewer children overall had access to a medical home, but the pre-existing disparities in medical home access by children of lower SES families and racial/ethnic minority children did not change significantly over the time period. Disparities in parents' reported experiences with medical homes also did not change significantly over the studied time period.
The frequency of screening for social determinants of health, and pediatrician attitudes regarding this screening, was assessed using data from the American Academy of Pediatrics Survey for October 2014 toMarch 2015. The respondents included 732 non-retired members of the AmericanAcademy of Pediatrics. Most pediatricians (61.6%) felt that screening was important, but fewer (39.9%) reported that it was feasible; the most frequently screened-for needs included childcare (41.5%) and transportation barriers (28.2%).
A nested case-control study embedded in the cluster randomized control trial using the WE CARE tool, this study sought to examine the relationship between specific unmet material needs (i.e. food, housing, and employment) and reported infant maltreatment, using reported child protective services (CPS) cases. Cases and controls were mothers of children<1 year of age, who brought their infant to one of eight community health centers in Boston, MA. Multivariate analyses showed a statistically significant association between maternal unemployment and reports of suspected child maltreatment; food insecurity and housing insecurity were associated with higher odds of child maltreatment but did not reach statistical significance.
A cross-sectional study was performed in an urban teaching hospital-based pediatric clinic to describe the prevalence of basic social needs in a cohort of parents attending an urban teaching hospital-based pediatric clinic, and to assess the attitudes of parents and resident providers on seeking assistance and addressing those needs, respectively.Study participants included 100 parents, who reported a median of 2 basic needs at the visit, most commonly employment (52%) and education (34%); most parents (67%) reported positive attitudes towards requesting assistance from their child's pediatrician. Most pediatric residents (91%) believed that addressing social needs was important, but few reported routinely screening for these needs (range of 11-18%).
A randomized controlled trial evaluating the impact and feasibility of a 10-item self-report psychosocial screening instrument was performed at a medical home for low-income children, with participants including a total of 200 parents of children aged 2 months to 10 years of age. This WE CARE Survey Instrument assessed for psychosocial problems including unemployment, depression, intimate partner violence, and homelessness, and was linked to a Family Resource Book. Compared with the control group, parents in the intervention group discussed more psychosocial topics with their resident providers (2.9 vs 1.8), and had greater odds of having contacted a community resource at 1 month; most resident providers reported that the survey instrument did not slow the visit.
An analysis of semi-structured interviews with 11 community health center (CHC) clinicians and staff members who had previously participated in a Type 1 effectiveness-implementation cluster RCT. The RCT included 6 pediatric clinics in CHCs in Boston, MA with 3 of the clinics continuing standard care and 3 clinics randomized to implement an augmented WE CARE model (which included a screener designed to identify 6 social needs and whether families wanted assistance with them, referral sheets for local resources printed directly from patient’s EMR, and a patient navigator assigned to support the referral process). CHC informants believed that the WE CARE model helped them to learn about patient and family unmet material needs that were otherwise unknown and to align their work with their clinic mission of holistic care. The screener itself was seen as relatively patient friendly and easy to implement due to its integration into the EMR-- although some informants reported patient confusion regarding the format of the screener. Informants made clear that throughout the study there was a strong reliance on the patient navigator to fill gaps in the knowledge and time of clinicians to adequately connect families to resources. Informants also expressed frustration with the restrictive eligibility requirements and lengthy waitlists of some of the referral resources, which made it challenging and time-intensive to support patients and their families in resolving unmet material needs. The authors conclude by suggesting that effectively implementing WE CARE or other social determinants of health screening and referral models will require greater buy-in from clinicians and staff-- including naming a clinic champion tasked with investing in the model’s success-- and having the workflow and roles of different staff members more clearly defined and formalized a priori.
Commentaries and other publications
The medical home model, with its foundation in comprehensive and coordinated care, must also focus on interfacing with early intervention programs, schools, early childhood education and childcare programs, and other community agencies in order to provide the most effective care possible. The interaction of the medical home with community-based, non-medical services can allow for the creation of a “ health neighborhood”. A health neighborhood should be able to identify the basic needs of its patients and facilitate referrals, coordinate care, allow for co-location of services, and centralize community services.
Family psychosocial issues, which range from social needs to parent psychosocial problems, have a major influence on children's development and health. Screening and surveillance can be used to detect family psychosocial issues that affect pediatric patients, in the same way that they are now regularly used to monitor for developmental delays. To be capable of bringing about meaningful change, screening and surveillance for family psychosocial issues should be integrated with a referral process that links the medical home with community-based resources.
Given the important role that social and environmental factors play in health at all ages, surveillance for negative social determinants of health and social needs should be performed at all pediatric visits, and resource referrals should be triggered whenever necessary.Screening with validated tools should occur whenever surveillance detects a concern, and this screening should be tailored to the specific determinants that are most relevant to each family. By using these effective strategies, pediatricians can exert a greater effect on the health of pediatric patients and their families in a more efficient manner.
The policy shift away from a fee-for-service system towards accountable care organizations (ACO's) is likely to change the way that the healthcare system addresses the social circumstances of patients, particularly those covered by Medicaid. Challenges that have become more prominent during this shift include an inadequate safety net, financial incentives that are sometimes at odds with patient autonomy, and the diversion of resources towards “sicker” patients and away from others with similar social needs. New opportunities presented by ACO's include the creation of new organizations for coordinating care across diverse sectors, and the potential for improved reimbursement for social services delivered in a medical setting.
The usefulness of all screening tools is dependent on the prevalence of the screened-for condition in the population. Because it is necessary to screen large populations for social needs, which differ from one another considerably in terms of prevalence, this screening will often produce a high number of false-positive and false-negative results. This is a limitation that is common to all screening tools, but is one that providers should be particularly aware of when screening for social determinants of health. In this area, false-positive results can lead to unnecessary discussions which undermine the physician-patient relationship, and false-negative results can cause the failure to address a serious need.
Social determinants of health (SDH) are a significant contributor to health outcomes for patients of all ages, but other specialties have been slow to follow the example of the American Academy ofPediatrics in making official recommendations to screen for poverty-related social risk factors. The process of increasing consideration of these social and environmental factors in the practice of internal medicine would likely be accelerated by adopting new professional guidelines, promoting adaptable screening processes and referral instruments, performing additional research on the effects of SDH in preventing physician burnout, promoting clinical-community collaborations, and providing appropriate reimbursement.
Screening for social determinants of health differs from screening for traditional medical screening in that the needs uncovered by the former cannot be fully satisfied by the medical system alone. Keeping this in mind, it is important that a robust referral system be in place prior to undertaking screening for social determinants of health. Such a system decreases the risk that a need is revealed that the provider has no ability to assist with, which could potentially erode the physician-patient relationship. It is also important to remain patient-centered during this process, and to build on the existing strengths of each patient.
Publications and presentations by other teams using WE CARE
A review of the quality improvement (QI) initiative conducted from August 2017 to November 2018 in the pediatric hematology clinic serving around 200 patients with Sickle Cell Disease under the age of 21 years at Boston Medical Center—an academic, urban safety net hospital where 72% of patients have public insurance. The QI initiative utilized an adapted version of the WE CARE SDoH screening tool to systematically gather information about the unmet socioeconomic needs (including housing instability, food insecurity, employment/education status, utilities access, transportation to clinic*, and ability to pay for medication*) of the clinic’s patient population. In addition, the study aimed to understand whether the tool was an effective and feasible intervention in the pediatric hematology setting. Overall, the WE CARE tool was found to further identify the present high rates of unmet socioeconomic needs among the clinic’s patient population without overburdening the staff during its implementation. Next steps of the QI initiative include improving upon the clinic’s list of available community resources based on patient feedback about the effectiveness and ease-of-use after referral.
*Questions added to original WE CARE screening tool
An observational study implementing an adapted version of the WE CARE SDoH screening tool to analyze (1) the socioeconomic needs of the patient population at the primary care pediatric practice at the University of Rochester Medical Center in Rochester, NY (> 12,000 patients under 21 with more than 70% of patients on public insurance); (2) provider comfort discussing patient unmet material needs pre/post WE CARE implementation screener; (3) number of patient/family referrals by social workers to community services and organizations pre/post WE CARE implementation. The study concluded that WE CARE screening effectively identified previously unknown patient socioeconomic needs while also increasing provider comfort (on a 5 point Likert scale) and only minimally impacting clinic work flow.
An observational study conducted from August 1st, 2016 to February 28th, 2017 at four academic clinics in Chicago, Illinois serving urban, low-income and racially diverse patient populations, wherein all parents/guardians of children ages 2 weeks to 17 years at well-child visits received a questionnaire (ASK Tool) including elements of adapted WE CARE survey, SEEK screening tool, and ACE screening questionnaire. The study sought to determine whether a tool that combined screening for unmet socioeconomic needs with screening for ACES (Adverse Child Experiences) could increase identification of toxic stress indicators in patients/families and referral to support resources. A subset of parents/guardians also consented to surveys evaluating their experience of using the ASK Tool. Each of the four clinics developed site-specific community resource lists aligned with each ASK question, which were provided when parent/guardian indicated wanting assistance and supplemented social worker availability. The rate of referrals to community resources increased by more than 6-fold at the 1 clinic where this variable was measured. Overall, the study found that the universal screening for risk factors associated with toxic stress improved the identification and referral of patients/families with unmet socioeconomic needs but did not improve identification of patients with ACEs, which could be due to lack of parent/guardian comfort in answering questions about traumatic events.
Pediatric center at East Tennessee State University developed adapted version of WE CARE model—Team Care and subsequently administered screening at annual well child visits, as well as warm handoffs to social work interns if parents/guardians indicated desire for assistance.
A cross-sectional study of EMR data from urban safety-net hospital-based clinic visits by 3345 children 6-11 years of age, which sought to measure the association between social risks and mental health. Psychiatric symptoms were measured using the Pediatric Symptom Checklist-17 (PSC-17), and social risks were assessed using the WE CARE screener. Utilizing these tools together allowed for an analysis of the impact of both cumulative and individual social risks on the development of specific psychiatric symptoms in children. A quarter of the sample had at least one social risk as determined through WE CARE screeners, and 10% had a positive PSC-17 score, which indicated psychosocial dysfunction. Cumulative social risks predicted significantly increased odds of a positive PSC-17 score, with 3 WE CARE social risks representing the point at which children with positive PSC-17 scores could be most reliably distinguished from those without a positive score. In terms of individual social risks, food insecurity and parental employment were significantly associated with a positive PSC-17 score, but after adjusting for sociodemographic characteristics and other social risks, only food security remained significantly associated with a positive PSC-17 total score.