The WE CARE Model
WE CARE is a social determinants of health (SDoH) screening and referral intervention. SDoH are the social circumstances in which people are born, work, live, and age, that affect disparities in risk and in health outcomes through a myriad of physiological and behavioral pathways.
WE CARE is a relatively simple intervention that has two key components (and an optional third):
- The WE CARE Survey
- Community Resource Information Sheets
- (Optional) Additional support staff, such as patient navigators, case managers, or social workers
The WE CARE Survey instrument is designed to: (1) identify unmet social needs (e.g., childcare, employment, and housing) by self-report (e.g., "Are you employed?"), and (2) using a family-centered approach, determine whether parents would like assistance with any of their unmet needs (e.g., "If no, do you want help?"). The "would you like help?" question avoids the common screening pitfall of presuming that those who have a need want assistance addressing it.
Respondents can indicate whether they want help by marking "Yes," "No," or "Maybe Later." Critically, the "Maybe Later" option ensures parents know they can always access resources in the future if they are not ready to now.
Families who report wanting help should be provided with locally developed Community Resource Information Sheets (see below).
The WE CARE Survey has evolved in Dr. Garg's prior studies in order to tailor it to the needs of the specific patient populations and the resources available in the surrounding communities. Each iteration of our team's carefully crafted, family-centered WE CARE survey is available to download and use, free of charge. Please complete the following information in order to access the WE CARE survey:
Families who report having a need and wanting help should be provided with the corresponding WE CARE Community Resource Information Sheet. These 1-page information sheets list community resources (e.g., food pantries) and their contact information (e.g., telephone number) for each specific WE CARE need (e.g., food insecurity). Because community resources vary widely depending on neighborhood, city, and state, WE CARE information sheets should be specific to each clinic. The sheets should also be written at a reading level suitable for your clinic's families.
The two most popular options for maintaining and distributing Community Resource Information Sheets are:
1. WE CARE Family Resource Book
The Family Resource Book is a binder that has separate tabs for each unmet social need assessed on the WE CARE survey. Each tab contains multiples copies of need-specific Community Resource Information Sheets. Copies of the Family Resource Book should be available in each of your clinic's exam rooms so that every time a provider reviews a WE CARE survey, they can engage the family in a conversation about their unmet social needs and provide them with the appropriate resources.
- Can be done without relying on EHR if EHR is not available or not working
- Can be provided by any office staff
- Needs to be refilled
- Can't keep track of whether sheet has been given to family or not yet
2. EHR Integration of WE CARE Resource Information Sheets
As electronic health record (EHR) capabilities have increased, so too have opportunities for integrating surveys, screening instruments, and patient handouts. Some clinics have chosen to integrate the WE CARE referral process into their EHR systems. For instance, EHR smart phrases can be used to add WE CARE Community Resource Information Sheets to patients' visit summaries. Please consult your clinic's EHR Administrator to discuss how to achieve this in your EHR system.
- Can be printed directly from EHR (less paper waste)
- Can be tracked in patient's EHR (e.g. "food" handout printed in Feb 2019)
- Potential cost of embedding resource information sheets into EHR
Regardless of which approach you choose, please remember to regularly review your clinic's handouts to ensure that they are up-to-date! Community resources' contact information and availability can change over time, and new resources are always being added. We recommend reviewing your Community Resource Information Sheets at least every 6 months.
One option for augmenting the WE CARE model is to utilize patient navigators or other support staff to help link families to community resources. They can offer families personalized guidance with accessing community resources through flexible problem-solving to overcome barriers to care. Patient navigators have been traditionally utilized in the adult health care setting to enhance screening and diagnosis for a variety of health conditions (particularly with cancer patients); however, they can be valuable members of any care team by helping to connect low-income families to community services. Patient navigator responsibilities can vary widely, but they should include meeting with families at periodic visits, offering support, helping families submit resource applications, and even accompanying families to community services if desired.
Keys to Successful Implementation
Our team has worked with dozens of pediatric clinics to implement the WE CARE model, and through our successes and challenges, we have identified a few tips to help WE CARE be successful at your clinic.
1. Clinic buy-in—at every level
In order to successfully and sustainably implement even a simple intervention, it is critical to gather support not only from clinic leadership, but also from front desk staff, medical assistants, nurses, physicians, social workers—the list goes on and on. Buy-in can best be achieved through education. Teach your clinic about the importance of addressing your patients' unmet social needs. If you need a place to start, please check out some of our research (hyperlinked), which has contributed to the growing evidence- base supporting the WE CARE model.
2. Commit to a process, but be flexible if something isn't working
Before your team rolls out WE CARE, work together to determine a process and commit to it for a few weeks. Designate clear roles, asking each other who in your clinic should:
- Provide the WE CARE survey to families
- Discuss survey responses with families
- Provide the appropriate Community Resource Information Sheets
- Ensure the clinic has enough copies of the WE CARE screener (and in all the languages spoken by your patients' families)
- Maintain the Family Resource Book or WE CARE EHR Handouts
If after adhering to a clear workflow your team runs into issues, regroup and rework the workflow.
3. Listen to patient feedback.
By listening to your patients' feedback, your team will have a better understanding of how to optimize the WE CARE model for your specific clinic's unique patient population. Patients'& families might have suggestions regarding reducing or increasing screening frequency, choosing resources relevant to patients who live far from where they get care, or improving any& other aspects that could be going better.
4. Keep at it!
Pediatric clinics are busy environments wherein new recommendations and policy changes are happening along with constantly shifting roles, workflows, and responsibilities. Be patient with yourself and with your team as you go through these changes. It takes time to fully implement even simple interventions like WE CARE—keep at it, and remember that WE CARE represents a huge step toward addressing your patients' unmet social needs and potentially improving their health and development.
Marmot M, Wilkinson RG. Social determinants of health. New York: Oxford University Press; 2006.
Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246.
Shonkoff J, Phillips D, eds. From neurons to neighborhoods. Washington, DC: National Academy Press; 2000.
Dohan D, Schrag D. Using navigators to improve care of underserved patients: current practices and approaches. Cancer. 2005;104:848-855.
Freeman HP. Patient navigation: a community based strategy to reduce cancer disparities. J Urban Health. 2006;83:139-141. PMCID2527166.
Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61:237-249.