Introduction: Screening and referral for Social and Behavioral Determinants of Health (SDOH) are increasingly recommended in clinical guidelines and consensus statements. It is important to understand barriers and facilitators to implementation of standardized SDOH screening and referral practices, as well as the scope of current existing SDOH screening.Methods: We conducted a mixed-methods study to understand the current state of SDOH screening and to assess the barriers and facilitators to implementing a standardized SDOH screening and referral practice in Boston community health centers (CHCs) for pediatric patients. We requested all SDOH screening documents from 15 Boston CHCs and conducted provider and staff focus groups at intervention sites of an SDOH implementation pilot in Boston.Results: All CHCs screened in some form for SDOH, but there was no agreement on which domains to screen. Participating CHCs screened for a mean of 8 SDOH domains (range, 5 to 16). Overall, 16 SDOH domains emerged. From the focus groups, 5 themes emerged: 1) provider perspectives, 2) work flow, 3) prior experience, 4) site resources and staffing, and 5) sustainability. There was little agreement among participants within each theme, as all were seen as barriers and facilitators depending on the respondent.Discussion: This study highlights the various SDOH screening methods currently used in Boston CHCs, and the need for workflow and process individualization of SDOH screening and referral. Providers and clinical staff should be part of the discussion when implementing SDOH screening and referral procedures to ensure appropriate work flow, staff buy-in, and to maximize resources available. (J Am Board Fam Med 2019;32:297-306.)
Purpose: Screening for social determinants of health (SDOH) during primary care office visits is recommended by pediatric and internal medicine professional guidelines. Less is known about how SDOH screening and service referral can be successfully integrated into clinical practice. Methods: Key informant interviews with 11 community health center (CHC) clinicians and staff members (medical assistants and case managers) were analyzed to identify themes related to integrating a SDOH screening and referral process (augmented WE CARE model) into their workflow. Results: CHC clinicians and staff believed the augmented WE CARE model benefited their patients and the CHC’s mission. Most clinicians found the model was easy to implement. Some staff members had difficulty prioritizing the nonclinical intervention and were confused about their roles and the role of the patient navigator. The eligibility requirements and time needed to access local SDOH resources frustrated clinicians. Discussion: SDOH screening and referral care models can help support the mission of CHCs by identifying unmet material needs. However, CHCs have organizational and administrative challenges that successful interventions must address. CHCs need clinical champions for SDOH models because the screening and follow-up processes involve clinical staff. Additional support for SDOH models might include piloting the SDOH screening model workflow and formalizing the workflow before implementation, including the specific roles for clinicians, staff, and patient navigators.
OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS:We conducted a randomized comparative effectiveness trial of 2 care management systems for 6-to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year.RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28).CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care. WHAT'S KNOWN ON THIS SUBJECT:Collaborative care is known to be an effective system to manage child behavioral health conditions in the primary care setting. WHAT THIS STUDY ADDS:Among urban children with attention-deficit/hyperactivity disorder, using lay care managers to address barriers to engagement with care and challenging child behaviors has the potential to improve the effectiveness of conventional collaborative care. Dr Silverstein conceptualized and designed the study, oversaw its implementation, and drafted the initial manuscript; Drs Hironaka and Walter conceptualized and designed the study, oversaw its clinical implementation, reviewed and revised the entire manuscript, and assisted in the interpretation of analyses; Dr Feinberg assisted in conceptualizing and designing the study, oversaw its clinical implementation at one site, assisted in the interpretation of analyses, and reviewed and revised the manuscript; Ms Sandler managed the data for the project, assisted in preparing the analyses, and reviewed and revised the manuscript; Ms Pellicer supervised the care managers for the project, and reviewed and...
Diagnosing attention deficit hyperactivity disorder (ADHD) requires reports of child behavior from 2 settings-most commonly home and school. Obtaining this information from teachers, however, is often challenging. We sought to determine if clinical data, supplementary to parent symptom scales, could be useful in predicting DSM-compliant diagnoses. Parents and teachers reported ADHD symptoms for 156 children using Vanderbilt scales; care managers collected clinical data; a team of specialists determined whether children met diagnostic criteria for ADHD. The ability of a parent Vanderbilt alone to predict an ADHD diagnosis was 56% (95% confidence interval = 45%, 67%). By adding child age and grade retention history to the multivariable model, the probability rose to 78% (95% confidence interval = 59%, 93%). In the maximally predictive model-which included 5 covariates-the predictive validity rose to 84% (95% confidence interval = 52%, 99%). Supplementing parent symptom reports with clinical data may be a viable alternative in certain cases when teacher reports are unavailable.
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