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Research and Publications

A cluster randomized control trial at 8 urban communityhealth centers, in which 336 mothers, mostly with household incomes<$20,000 and multiple unmet social needs, were enrolled. Those in theintervention 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 likelyto be enrolled in a new community resource and at follow-up had greater oddsof being employed, their children had greater odds of being in childcare, andthe entire family had lower odds of living in a homeless shelter.

A mixed-methods study which collected and analyzed thesocial determinants of health (SDOH) screening forms from 15 Boston CommunityHealth Centers serving a majority low-income (<200% FPL) population, andconducted focus group interviews on provider implementation experiences withthe WE CARE SDOH screening tool. A total of 16 domains of SDOH were screenedfor at these sites, including material hardship, trauma/violence, andhousing, with housing being the most commonly screened-for domain. The focusgroups, which included physicians, nurses, and medical assistants, variedconsiderably on what they saw as barriers or facilitators during WE CAREscreening, and frequently-addressed themes included provider perspectives andclinic workflow.

The frequency of screening for social determinants ofhealth, and pediatrician attitudes regarding this screening, was assessedusing 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 wasimportant, but fewer (39.9%) reported that it was feasible; the mostfrequently screened-for needs included childcare (41.5%) and transportationbarriers (28.2%).

A nested case-control study embedded in the clusterrandomized control trial using the WE CARE tool, this study sought to examinethe relationship between specific unmet material needs (i.e. food, housing,and employment) and reported infant maltreatment, using reported childprotective services (CPS) cases. Cases and controls were mothers of children<1 year of age, who brought their infant to one of eight community healthcenters in Boston, MA. Multivariate analyses showed a statisticallysignificant association between maternal unemployment and reports ofsuspected child maltreatment; food insecurity and housing insecurity wereassociated with higher odds of child maltreatment but did not reachstatistical significance.

A cross-sectional study was performed in an urban teachinghospital-based pediatric clinic to describe the prevalence of basic socialneeds in a cohort of parents attending an urban teaching hospital-basedpediatric clinic, and to assess the attitudes of parents and residentproviders on seeking assistance and addressing those needs, respectively.Study participants included 100 parents, who reported a median of 2 basicneeds at the visit, most commonly employment (52%) and education (34%); mostparents (67%) reported positive attitudes towards requesting assistance fromtheir child's pediatrician. Most pediatric residents (91%) believed thataddressing social needs was important, but few reported routinely screeningfor these needs (range of 11-18%).

A randomized controlled trial evaluating the impact andfeasibility of a 10-item self-report psychosocial screening instrument wasperformed at a medical home for low-income children, with participantsincluding a total of 200 parents of children aged 2 months to 10 years ofage. This WE CARE Survey Instrument assessed for psychosocial problemsincluding unemployment, depression, intimate partner violence, andhomelessness, and was linked to a Family Resource Book. Compared with thecontrol group, parents in the intervention group discussed more psychosocialtopics with their resident providers (2.9 vs 1.8), and had greater odds ofhaving contacted a community resource at 1 month; most resident providersreported that the survey instrument did not slow the visit.

Commentaries and other publications

The medical home model, with its foundation incomprehensive and coordinated care, must also focus on interfacing with earlyintervention programs, schools, early childhood education and childcareprograms, and other community agencies in order to provide the most effectivecare possible. The interaction of the medical home with community-based,non-medical services can allow for the creation of a “health neighborhood”. Ahealth neighborhood should be able to identify the basic needs of its patientsand facilitate referrals, coordinate care, allow for co-location of services,and centralize community services.

Family psychosocial issues, which range from social needsto parent psychosocial problems, have a major influence on children'sdevelopment and health. Screening and surveillance can be used to detectfamily psychosocial issues that affect pediatric patients, in the same waythat they are now regularly used to monitor for developmental delays. To be capableof bringing about meaningful change, screening and surveillance for familypsychosocial issues should be integrated with a referral process that linksthe medical home with community-based resources.

Given the important role that social and environmentalfactors play in health at all ages, surveillance for negative socialdeterminants of health and social needs should be performed at all pediatricvisits, and resource referrals should be triggered whenever necessary.Screening with validated tools should occur whenever surveillance detects aconcern, and this screening should be tailored to the specific determinantsthat are most relevant to each family. By using these effective strategies,pediatricians can exert a greater effect on the health of pediatric patientsand their families in a more efficient manner.

The policy shift away from a fee-for-service systemtowards accountable care organizations (ACO's) is likely to change the waythat the healthcare system addresses the social circumstances of patients,particularly those covered by Medicaid. Challenges that have become moreprominent during this shift include an inadequate safety net, financialincentives that are sometimes at odds with patient autonomy, and thediversion of resources towards “sicker” patients and away from others withsimilar social needs. New opportunities presented by ACO's include thecreation of new organizations for coordinating care across diverse sectors,and the potential for improved reimbursement for social services delivered ina medical setting.

The usefulness of all screening tools is dependent on theprevalence of the screened-for condition in the population. Because it isnecessary to screen large populations for social needs, which differ from oneanother considerably in terms of prevalence, this screening will oftenproduce a high number of false-positive and false-negative results. This is alimitation that is common to all screening tools, but is one that providersshould be particularly aware of when screening for social determinants ofhealth. In this area, false-positive results can lead to unnecessarydiscussions which undermine the physician-patient relationship, andfalse-negative results can cause the failure to address a serious need.

Social determinants of health (SDH) are a significantcontributor to health outcomes for patients of all ages, but otherspecialties have been slow to follow the example of the American Academy ofPediatrics in making official recommendations to screen for poverty-relatedsocial risk factors. The process of increasing consideration of these socialand environmental factors in the practice of internal medicine would likelybe accelerated by adopting new professional guidelines, promoting adaptablescreening processes and referral instruments, performing additional researchon the effects of SDH in preventing physician burnout, promotingclinical-community collaborations, and providing appropriate reimbursement.

Screening for social determinants of health differs fromscreening for traditional medical screening in that the needs uncovered bythe former cannot be fully satisfied by the medical system alone. Keepingthis in mind, it is important that a robust referral system be in place priorto undertaking screening for social determinants of health. Such a systemdecreases the risk that a need is revealed that the provider has no abilityto assist with, which could potentially erode the physician-patientrelationship. It is also important to remain patient-centered during thisprocess, and to build on the existing strengths of each patient.