Pediatric health systems have joined the movement to screen families for social needs impacting their health. During a Population Health Colloquium panel session on Oct 12, several executives described their attempts to standardize screening processes and move from screening to closing the loop with community-based organizations.
Kara Walker, M.D., M.P.H., executive vice president and chief population health officer in the Office of Policy & Prevention at Nemours Children's Health System, said Nemours officials have been thinking about how to implement a screening tool to look at social factors across their enterprise in Delaware and Florida. “We wanted to understand how patients and families would perceive these questions, how our staff would feel comfortable implementing the screeners, and also understand what it means to collect this data on patient needs,” she said. “We've been integrating it into our electronic medical record, and trying to understand more about who was most likely to report a need.
Nemours initially asked social needs questions to 450 participants from randomly selected families. “We found that 55 percent reported at least one social need,” Walker said. “We're trying to move beyond just asking the question, but also to understand how it impacts our workflow, how it impacts our electronic medical record, and how we think about addressing these needs, which is the ultimate goal.”
In addition to choosing a screening tool, Walker said, it is important to think through the workflow design about how the referrals and interventions will be handled. “Thinking about the existing connections with your community service organizations is critical,” she said. “We realize that this is an ongoing learning opportunity, with constantly sought feedback from everyone involved to continue to refine and improve the process.”
Standardizing screening at Kaiser Permanente
Anand Shah, M.D., vice president of social health for Kaiser Permanente, also spoke about the importance of standardization to integrate social practice into a large organization such as KP.
“We are implementing a tool across our enterprise to help people connect to services,” Shah said. “We're also growing interventions to help address individual-level social risk and needs, and doing so in a way that is integrated into their care experience. We want to do that so it is predicated on understanding the social context of where people are coming from.”
Shah noted that there is still a lot of learning to do about what's the right way to ask these questions and what's the right intervention. How effective are they? What's the potential for harm? “We're learning that the prevalence of social needs in our population is high. We found that 60 percent of Americans reported a social need in the past year in our member population. And 90 percent of those who we surveyed actually wanted their health system to be asking these questions.”
Getting back to the screening standardization issue, KP surveyed its organization and found they had more than 70 different instruments being used. “We're trying to move towards a more standard approach,” Shah said. “We had an enterprise goal of hitting half a million screens this year, and we've surpassed that. We want to make sure that we create different doors for people to be able to walk through if they're comfortable addressing these questions — that can be in the care setting, that can be at their home, that can be in a mobile digital environment, that can be during health plan interactions.”
Shah added that the work of identifying and addressing social needs is also connected to work Kaiser has been doing to help understand trauma that patients and families are experiencing. The organization has been screening for adverse childhood experiences in Southern California for over three years, and now six of its eight markets are screening for ACEs. “We're working to make sure that this is happening in a coordinated fashion with an understanding of some of these other social domains,” he said.
Linking screening to interventions at Cincinnati Children's
Andrew Beck, M.D., M.P.H., an attending physician at Cincinnati Children's Hospital Division of General & Community Pediatrics, said his organization is “trying to think about how screening can be connected to action, how we can help to open as many doors as possible and find additional doors through which our patients can both find their way to us and we can find our way to additional interventions out in the community.”
Beck said one key objective is to link approaches to screening for health-related social needs with potential intervention strategies, both within the healthcare setting and in partnership with community agencies and organizations.
One of their approaches has been to build what they call a health equity network, with clinical teams from across primary care and subspecialties at Cincinnati Children's focusing on decreasing gaps in health outcomes, in part by understanding common drivers across those conditions at clinics and sharing strategies that emerged from case discussion, and explicitly encouraging and obtaining the voice of the customer — that is the voice of the child, the family, the patient, to identify what matters to them.
“It involves us thinking about a culture of equity much as we think of a culture of safety, and a lot of this work has been driven through what we call the All Children Thrive Learning Network,” he said.
“We are seeing the importance of clinical/community partnerships that allow us to take a social need and meet it with an intervention,” Beck said. “These are partnerships that augment healthcare-based capabilities. An example is our Cincinnati Child Health Law Partnership, which has been pursuing what we like to consider both population health and population justice since 2009,” he explained. “Since that time, we've had about 10,000 referrals and 25,000 individuals assisted from our primary care centers, almost $1 million in public benefits recovered, reduced risks related to poverty patterns recognized in certain hot spots, and evidence which we're currently looking at and hope to submit for publication soon, that referrals reduce subsequent hospitalizations.”
Real-time match-making in Colorado
Heidi Baskfield, J.D., vice president of population health and advocacy at Children's Hospital Colorado, said that in addition to launching a social need screening tool, Children’s Hospital Colorado has begun to offer real-time dedicated match-making between families and community organizations once a need has been identified.
The hospital has deployed a screening tool and patient complexity score, which live within the Epic EHR system, to inform the interventions.
“We've created a center called the Resource Connect Center on the fourth floor of our new Health Pavilion,” Baskfield said. “It is a place where partners that are part of our community link up with families the moment after they walk out of the clinic visit to work on those things that they identified on our screener. If you have a family that identifies food, housing, benefits, energy assistance, WIC, legal needs or even childcare, you're able to walk upstairs to the Resource Connect Center and have those needs met,” she said. For families who are identifying food insecurity as a need, for example, they have a food pharmacy, so families can get a two-week supply of both shelf-stable and fresh fruit and produce. “At the same time, we're getting families who are eligible linked in to their SNAP benefits. Similarly, we have a dedicated navigator helping families address housing needs, and coming soon to the Resource Connect Center we'll be adding some support around workforce development and economic security.”
Children’s Hospital Colorado is measuring the impact of these interventions. “It is not only important to measure and understand whether or not your families are getting their needs met, whether you've got the right partners, but what's the ‘so what’ within the larger healthcare context,” Baskfield said. “We're beginning to connect the dots between our use of Resource Connect, and things that payers, in particular, care a lot about, including ED utilization.
“We're pretty excited that we're already beginning to show in an early pre- and post-analysis that families who are benefiting from the services in our Resource Connect Center are starting to see a different level of emergency department utilization — in the right way — they aren't needing it as much,” Baskfield said. “Coming soon, we will be measuring in a similar way well-child visit adherence and immunization adherence as well. We're really excited about the prospects for what can come as far as creating a more scalable and sustainable model to real-time delivery of social determinants health needs.”
