Arvin Garg

Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project.

OBJECTIVE. Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children. PATIENTS AND METHODS. A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study. RESULTS. Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit. CONCLUSIONS. Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents.

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

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 <

Avoiding the Unintended Consequences of Screening for Social Determinants of Health

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.

Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics

Screening for social determinants of health, which are the health-related social circumstances (eg, food insecurity and inadequate or unstable housing) in which people live and work, has gained momentum as evidenced by the recent Centers for Medicare & Medicaid Services innovation initiative of

The Value of the Medical Home for Children Without Special Health Care Needs

157 million toward creation of accountable health communities.1 Funding will allow grantees to test a novel model of health care that includes identifying and addressing social determinants of health for Centers for Medicare & Medicaid Services beneficiaries. The initiative promotes collaboration between the clinical realm and the community through screening of beneficiaries to (1) identify unmet health-related social needs and (2) assist high-risk beneficiaries (ie, >2 emergency department visits and a health-related social need) with accessing available community services. Some health policy makers have embraced screening of social determinants as the next hope for achieving the triple aim of better health, improved health care delivery, and reduced costs because social and environmental factors are thought to contribute half

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Socioeconomic disparities in health continue to exist, despite advances in medicine.1 Since the classic Whitehall studies, it has been well known that the social context in which an individual lives and works influences health.2- 3 Mitigating the harmful consequences of social factors that contribute to health disparities has largely been left to the public health and policy communities, whereas clinical medicine has traditionally focused on identifying and reducing biological risk factors for an individual patient. The patient-centered medical home (PCMH), however, offers an important opportunity to promote population health through systematically addressing the social determinants of health.

Addressing Families’ Unmet Social Needs Within Pediatric Primary Care The Health Leads Model

Objective: Although the medical home is promoted by the American Academy of Pediatrics and the Affordable Care Act, its impact on children without special health care needs is unknown. We examined whether the medical home is associated with beneficial health care utilization and health-promoting behaviors in this population. Methods: This study was a secondary data analysis of the 2003 National Survey of Children’s Health. Data were available for 70 007 children without special health care needs. We operationalized the medical home according to the National Survey of Children’s Health design. Logistic regression for complex sample surveys was used to model each outcome with the medical home, controlling for sociodemographic characteristics. Results: Overall, 58.1% of children without special health care needs had a medical home. The medical home was significantly associated with increased preventive care visits (adjusted odds ratio [aOR]: 1.32 [95% confidence interval (CI): 1.22–1.43]), decreased outpatient sick visits (aOR: 0.71 [95% CI: 0.66–0.76), and decreased emergency department sick visits (aOR: 0.70 [95% CI: 0.65–0.76]). It was associated with increased odds of “excellent/very good” child health according to parental assessment (aOR: 1.29 [95% CI: 1.15–1.45) and health-promoting behaviors such as being read to daily (aOR: 1.46 [95% CI: 1.13–1.89]), reported helmet use (aOR: 1.18 [95% CI: 1.03–1.34]), and decreased screen time (aOR: 1.12 [95% CI: 1.02–1.22]). Conclusions: For children without special health care needs, the medical home is associated with improved health care utilization patterns, better parental assessment of child health, and increased adherence with health-promoting behaviors. These findings support the recommendations of the American Academy of Pediatrics and the Affordable Care Act to extend the medical home to all children.

From Medical Home to Health Neighborhood: Transforming the Medical Home into a Community-Based Health Neighborhood

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Redesigning Health Care Practices to Address Childhood Poverty

The Institute of Medicine has stated that “practicing in the context of family and community” is a fundamental tenet of primary care. This is particularly important in pediatrics, where social determinants of health powerfully shape children’s well-being. Prior studies have demonstrated the impact that family psychosocial issues (eg, poverty, food insecurity, and housing instability) can have on children’s health and development. Pediatric professional guidelines including the Bright Futures health supervision guidelines recommend that primary care providers address the social milieu of their patients; however, few routinely do so. Provider barriers include lack of time, professional training, and knowledge of community resources. Within the medical home, innovative multidisciplinary team-based approaches are needed to assist providers with identifying social problems and referring families with unmet needs to available community-based resources, particularly for low-income populations where basic material needs are common. Nonmedical team members have traditionally included social workers, community outreach workers, patient navigators, and lawyers. This report describes a new management approach to addressing families’ unmet social needs within pediatric primary care, namely, using volunteer undergraduate students to assist providers with their patients’ social needs. Health Leads (HL; formerly Project HEALTH) is a nonprofit organization, founded in 1996 at Boston Medical Center (formerly Boston City Hospital), that places undergraduate students in urban clinics to assist impoverished families with their social needs. Currently, HL operates 21 help desks at urban medical homes across the United States; approximately 800 students from 12 universities serve 9000 families annually. We describe the impact of the HL model on families’ receipt of community-based resources at an urban pediatric clinic. This integrated care model includes (a) parents completing a brief previsit screening survey for social issues (eg, food, housing, employment, etc) at well-child care visits, (b) providers referring to the HL desk located in the clinic, and (c) HL students connecting families to community-based resources through in-person meetings and telephone follow-up. HL students then update referring providers about outcomes (see Figure 1).

Influence of Maternal Depression on Household Food Insecurity for Low-Income Families

From the Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, MA; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; and Connecticut Children’s Medical Center, Hartford, CT; and Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH Social Determinants and the Medical Home