From Screening to Support: Crafting Social Needs Response Systems That Work for Families

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In this issue of Pediatrics, Garg et al1 detail findings from a multi-institutional stepped-wedge cluster trial using a type 2 hybrid effectiveness-implementation design. The study sought to assess the impact of the Well-Child Care Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) social intervention. WE CARE—inclusive of a health-related social need (HRSN) screener and access to family resource books with referral handouts—was significantly associated with increased rates of screening and referral but not enrollment in community resources. Study strengths include its implementation across heterogeneous sites nationwide and pragmatic assessment of intervention effectiveness in real-world settings. Mixed findings led the authors to “temper expectations” relating to impacts of social care approaches implemented within medical settings and to caution that current approaches may be insufficient to fully address identified needs.2 Even so, the authors suggest that discussion of HRSNs, with or without direct connection to resources, could affect health outcomes through indirect pathways, including enhancement of “authentic healing relationships.”1,3Garg et al reach these conclusions given patterns identified when their WE CARE group is compared with a usual-care group. A higher percentage of parents reported discussion of HRSNs such as food, utilities, childcare, and housing in the WE CARE group. Similarly, more WE CARE parents reported referrals to community resources, most commonly for support related to childcare, utilities, and food. However, there were no differences in community resource enrollment between study groups after 3 months of follow-up, and it was not clear whether medical or social outcomes improved as a result of the intervention.1Limited effects of interventions like WE CARE on resource enrollment and limited measurement of the impact of such interventions on meaningful, measurable medical and social outcomes are the crux of current debates about the how, what, and when of HRSN screening and response. Confluent medical and social needs clearly affect health and well-being for children and their families. Still, how we identify and respond to HRSNs in medical settings is far more opaque, even as screening proliferates.4 Does it matter how we ask, what we ask, who asks, and how we document and use results? What constitutes a meaningful response? Is screening alone an intervention? How are referrals to external resources best made? Is providing a paper handout or resource list sufficient? Are warm handoffs and processes that bridge medical and social care more effective? Are such processes realistic in the brevity of a patient encounter? Questions abound—relating to how we screen, respond, and partner.Screening for HRSNs is an established component of pediatric primary care.5 Although there is no established, singular, “right” way to screen, approaches that ensure patients and families feel comfortable sharing needs are paramount. Approaches that engender a reasonable expectation that clinicians will respond with empathy and effective solutions are even better. Within clinical settings, logistical considerations include workflow, delivery methods (eg, paper vs electronic), screening logic and firing frequency, clinician and staff training, and delineation of roles and their responsibilities for reviewing and responding to positive screening results. HRSN screening must also be balanced with other screeners (eg, child development, mental health), delivered equitably to avoid bias, and responsive to families’ circumstances.It is incumbent upon clinical teams to consider not only how to screen effectively but also how to respond, even if a response does not always lead to connections to tangible supports. For example, Garg et al note that among WE CARE parents, housing was the least discussed HRSN, perhaps due to a lack of effective solutions.1 We should consider whether simply asking about and acknowledging housing concerns is an intervention in and of itself, one that helps to contextualize care plans and increases parent engagement and trust with their child’s medical team.1,3 Alternatively, we should consider the potential for unintended consequences when asking about HRSNs without having ready responses, which could serve to decrease engagement and trust.Having effective responses for when families indicate an unmet need would be optimal. But what constitutes an effective response? We suggest that such responses must be informed by patients’ and families’ lived experiences. A system of tiered response, based on risk stratification and capacity and capability of the health care team to respond, offers a model that could facilitate equitable solutions. Responses could involve connecting patients with immediate safety or discharge concerns to a social worker, referring families with insurance needs to financial advocates or community health workers, and providing families with less acute needs with curated lists from community resource directories (eg, WE CARE’s Family Resource Books, United Way 211, Findhelp). Innovations in the electronic health record could provide the health care team with visibility to screening results and opportunities to connect families to such lists through after-visit summaries, discharge instructions, and patient/parent portals (eg, MyChart).1,2,4–8Our responses can, and likely should, go further. Among the most valuable tools for responding to families’ HRSNs are effective clinical-community partnerships capable of connecting patients and families with expertise and support outside the walls of the health care system.9–13 How can we partner in ways that benefit members of both medical and social care teams and, critically, our patients and their families? Garg et al note that of participants with available follow-up data, only 23% of families in the intervention group and 22% of families in the usual-care group reported enrollment in new community resources.1 We do not know whether participants who were lost to follow-up in either group enrolled in community resources. Drops from screening to referral to enrollment offer opportunities to explore how to open lines of communication between medical and social care partners, how to connect with community-based organizations and experts ready to care for our patients and their clients, and how to collaboratively troubleshoot barriers to enrollment.11Building bidirectional partnerships between medical and social team members, including community partner experts in addressing HRSNs, could meaningfully augment response capacity.8 It may also shift screening approaches toward those needs most addressable by partners ready and able to respond; such approaches may also highlight gaps across medical and social care environments. And we should seek co-designed innovations to fill these gaps—new ways to introduce community partners to families during clinical encounters (eg, brief videos, “telehealth” calls or consultations to increase the warmth of handoffs), bringing partners directly into medical settings (eg, co-location, waiting rooms as resource rooms), deploying clinicians to community settings (eg, school-based health, mobile units), and facilitating referrals to partners via social care extenders or navigators (eg, community health workers).7–12,14,15 We acknowledge that such partnerships often require more than 1 discussion and more than paper handouts. They benefit from a cross-sector learning system, inclusive of key voices seeking answers to new questions and challenges.13Discussions of social needs are now common across pediatric primary care, with growing frequency in subspecialty and acute care settings. However, screening does not always identify needs, nor does it always prompt referral to or enrollment in potentially helpful resources. Future research should push us to understand each step in the process from screening to response

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.