• Report
  • March 30, 2018

Screening for Social Determinants of Health: Children's Hospitals Respond

 Screening for Social Determinants report cover
View full white paper (PDF)

Summary: This report outlines how children's hospitals are implementing social determinant screening. Delivered in three parts and with many examples from peers, the report highlights the need for community resource connections, provides examples of screener tools being utilized, and offers questions to consider when implementing a new strategy to screen.

As the health care industry evolves, there's greater awareness of what factors contribute to health. Social determinants impact 20 percent of health, and children’s hospitals are tasked to identify and address them to improve patient health outcomes.

Responding to member inquiry, the Children’s Hospital Association set out to define tactics implementing social determinants screening, the community linkages needed and the inherent challenges they present. A representative sample of children’s hospitals contributed to this snapshot of where screening for social determinants stands, and what questions must be answered to bring the practice to scale throughout children's hospitals.

The following are key excerpts from the paper. 

Screenings: finding a tool to understand the whole patient

It’s been well over a decade since literature on the importance of addressing social determinants of health (SDoH) began to rise in prevalence. Defined by the CDC as “conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes1,” SDoH can include things like food scarcity/insecurity, homelessness or unsafe housing conditions, unemployment, and lack of access to care. Recognizing the profound impact of these factors, health care providers realize that they can no longer solely focus on the medical needs of their patients.

Children’s hospitals have an added level of complexity when trying to address social determinants of health, as the needs and context extend beyond the patient to include the family. Children with unmet social needs are familiar to those in the hospital, presenting as non-compliant, with frequent visits to the emergency department for inability to control chronic conditions or issues like failure to thrive. Additional signs often seen are stressed parents and/or children, an apparent lack of engagement in care or prolonged illness from persistent minor health problems. The consequences of these issues limits the impact of the medical care being provided, affecting the family’s engagement and the child’s overall health.2

A starting point: building community connections

One reason many hospitals don’t currently screen for SDoH is the uncertainty of how to address social needs when they are found. To overcome this, respondents suggest a good starting point for building a successful screening process inside the hospital is to establish community relationships outside the hospital. These relationships need to go beyond typical coalition building. It’s important to understand, and assess, the depth and breadth of resources provided by community and social service organizations in their catchment area, as well as their capacity for referrals.

Tools: selecting the right questions

For many, the issue of what comes first – the screener or the resource – is a tough one. While hospitals have taken different approaches, most report they don’t want to ask social needs questions until they have a way to do something with that information. That’s why the topic of building community connections appeared first in this paper. Once those are in place, hospitals can then move to determining which screening tool to use.

The following list provides a sampling of the screeners and referral platforms member hospitals are referencing. Screeners typically just refer to the set of questions being asked, while referral platforms help identify community resources and may involve care management.

 Name
Type
Description
ACES
Screener
Adverse Childhood Experiences Screener. Originally developed for adults, a validated pediatric version is available.
Accountable Health Communities Health-related Social Needs
Screener
Developed by the Center for Medicare and Medicaid Services (CMS) for use by their Accountable Health Communities and made publicly available. 
Hunger Vital Sign 
Screener
Two-question screening tool to identify households with food insecurity. Developed by Child Watch and endorsed by AAP
and CMS. 
iHELP 
Screener
Pediatric-focused screening tool developed by clinicians, which includes both household needs and child-specific questions.
Medical Legal Partnership 
Screener
A customizable screener that identifies legal needs. 
RAAPS-PH 
Screener
Rapid Assessment for Adolescent Preventive Services (RAAPS) is a tailored social needs screener for adolescents to young adults (ages 9 to 24). The “PH” version of the tool aims to further identify youth most at risk for access to tangible needs (food, water, electricity).
PRAPARE 
Screener
Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) is a comprehensive screening tool that includes 16 core measures as well as four optional measures. 
SEEK PQ 
Screener
Safe Environment for Every Kid Parent Questionnaire (SEEK PQ) screens parents for psychosocial issues and topics that impact safety for the child. 
SWYC 
Screener 
Survey of Well Being for Young Children (SWYC) screens children five and younger, and focuses on developmental milestones and family risk factors. 
WE-CARE 
Screener 
Validated tool that asks parents questions about child care, food security, housing, parent education and employment. 
Health Leads 
Screener/Referral Platform 
Both a screening tool and a platform for referral. Clients opt-in to this student-based, help-desk model for assistance. Hospitals elect which feature to use. 
Healthify/Purple Binder
 
Screener/Referral Platform
 Platform with software tools to identify resources, screen for SDoH, and track and coordinate referrals. Currently has contracts in 30 states.
HelpSteps 
Screener/Referral Platform
Developed by Boston Children’s Hospital based on a library of known screener tools. Offered in partnership with Boston Health
Department. Looking to expand beyond Massachusetts. 
Aunt Bertha 
Referral Platform
Uses zip code to identify resources for patient families, not a screening tool. 
NowPow 
Referral Platform
Uses zip code as well as patient- specific data to identify resources for patient families, not a screening tool. 
Unite Us 
Referral Platform
A referral platform with closed-loop capabilities. Initially focused on veterans, working on expansion to pediatrics.  


Implementation: starting small to make big changes

Building community connections takes time, effort and strategy. Selecting the best tool for your environment requires the same approach, followed by implementation of the new process. Questions quickly arise when the discussion shifts to implementation:

  • How do we institute another process without disrupting clinic flow?
  • How does SDoH screening interact with the other screenings already taking place?
  • Do we automate the process on tablets or computers? Use pen and paper?
  • Have it done person-to-person?
  • Who talks to the family about resources for a positive screen?
  • Do we institute a process that is referral only, or do we want to “close the loop” and know services were received?

Upon screening for social determinants, clinicians can

Social Determinants of Health evaluation flow chart


Moving past the why to improve health outcomes

Collaboration between clinicians and community to improve care for children can be found in the origin story of children's hospitals. That collaboration remains active today, and in many instances, is growing as evidence demonstrates the importance of addressing social needs to achieve positive medical outcomes. Our hospitals are large, complex institutions focused on providing high quality medical care. But without addressing the other risk factors impacting a patient’s life, medical care can only go so far. Initially, the conversations were focused on why changing the care delivery model from sick care to holistic health was important.

The questions throughout the paper can support your organization’s efforts to develop strategies that effectively address social determinants. The hospital examples can connect you with colleagues who found ways to integrate screening tools and uncover factors contributing to poor health outcomes. And because of their critical role in population health, children's hospitals can benefit from being part of the learning community offered by CHA. This focus on openly sharing best practices will ultimately improve children's health.

References 

  1. "Social Determinants of Health: Know What Affects Health," Centers for Disease Control and Prevention, accessed March 20, 2018.
  2. Context Counts: How Social Determinants of Health Impact Care Delivery,” Children's Hospital Association, published October 27, 2016.