Addressing Social Determinants of Health at Well Child Care Visits: A Cluster RCT

Abstract

OBJECTIVE: To evaluate the effect of a clinic-based screening and referral system (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE]) on families' receipt of community-based resources for unmet basic needs. METHODS:We conducted a cluster randomized controlled trial at 8 urban community health centers, recruiting mothers of healthy infants. In the 4 WE CARE clinics, mothers completed a self-report screening instrument that assessed needs for child care, education, employment, food security, household heat, and housing. Providers made referrals for families; staff provided requisite applications and telephoned referred mothers within 1 month. Families at the 4 control community health centers received the usual care. We analyzed the results with generalized mixed-effect models.RESULTS: Three hundred thirty-six mothers were enrolled in the study (168 per arm). The majority of families had household incomes ,$20 000 (57%), and 68% had $2 unmet basic needs. More WE CARE mothers received $1 referral at the index visit (70% vs 8%; adjusted odds ratio [aOR] = 29.6; 95% confidence interval [CI], 14.7-59.6). At the 12-month visit, more WE CARE mothers had enrolled in a new community resource (39% vs 24%; aOR = 2.1; 95% CI, 1.2-3.7). WE CARE mothers had greater odds of being employed (aOR = 44.4; 95% CI, 9.8-201.4). WE CARE children had greater odds of being in child care (aOR = 6.3; 95% CI, 1.5-26.0). WE CARE families had greater odds of receiving fuel assistance (aOR = 11.9; 95% CI, 1.7-82.9) and lower odds of being in a homeless shelter (aOR = 0.2; 95% CI, 0.1-0.9).CONCLUSIONS: Systematically screening and referring for social determinants during well child care can lead to the receipt of more community resources for families. WHAT'S KNOWN ON THIS SUBJECT:Although pediatric professional guidelines emphasize addressing a child' s social environment in the context of well child care, it remains unclear whether screening for unmet basic needs at visits increases low-income families' receipt of community-based resources. WHAT THIS STUDY ADDS:This study demonstrates that systematically screening and referring for social determinants of health during primary care can lead to the receipt of more community resources for families.

A Road Map to Address the Social Determinants of Health Through Community Collaboration

“…20 Many low-income families experience risks at multiple levels of this Hierarchy, risks that can have an undeniable impact on health and development. [22][23][24] Families confront issues related to food and housing insecurity at the base of the Hierarchy, as well as issues related to unemployment and lack of parenting support higher up on the Hierarchy. As we began to develop community interventions to address PPCC families' needs, Maslow's Hierarchy helped our team prioritize the risks we needed to focus on first and map them to appropriate interventions to more effectively help children reach their full potential.…”

“…Studies have demonstrated that the "meaningful use" of the electronic health record includes screening for risks related to the SDH. 24,39,45,46 This integration of the SDH into the electronic health record also may facilitate an enhanced awareness of available community resources in ways that promote improved outcomes for patients and families. 42 Determining which risks to screen for may follow from an early needs assessment of commonly identified risks.…”

“…Repeated interdisciplinary focus on clinician empathy and training along with embedded social history prompts in the electronic health record have proven beneficial to both family and provider engagement, improving rates of screening, identification of hardships, and interventions implemented. 24,41,43 Ensuring action as well as followthrough is a third key challenge. When referrals are placed for subspecialty consultation, many patients never go, and feedback loops to confirm follow-through rarely exist.…”

Children in nonparental care: health and social risks

“…While more research on the appropriate interventions to address these mechanisms is needed (29), research to date does indicate that providing services to address poverty in childhood does contribute to improved outcomes (19). Importantly, when healthcare providers are able to effectively identify the socio-environmental factors (including poverty) that place a child at risk for poor health outcomes, providers can effectively connect families to services that address those needs (30). Such interventions often need to target parenting behaviors known to be associated with poverty (29); whether changing caregivers addresses some of these issues for children entering nonparental care is not well understood.…”

Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico

“…3,4 Primary care providers experience a sinking feeling when after the clinical encounter, their hand on the doorknob to leave the examination room, their patient adds 1 more reason for the visit-perhaps they lost their job, are unable to afford their medicine, or are about to be evicted from their home. Screening for social needs has proven valuable for certain age groups: children during well-child visits, 5 patients with chronic habits such as smoking, 6 and high-risk patients with complex chronic diseases. 7 The WellRx pilot cast a wider net, evaluating the feasibility of systematically screening for and addressing patients' social needs during every visit in busy general primary care settings.…”