To develop and test the feasibility of a caregiver self-administered social needs screener, a Web-based searchable community resource map, and a process map for implementation of these tools as part of social needs screening and referral on a pediatric inpatient unit.
A multidisciplinary team used quality improvement methodology to develop an electronic social needs screener, resource map Web site, and electronic health record enhancements. A process map for implementation of these tools was refined through plan-do-study-act cycles before full implementation. Weekly measures included the number of eligible caregivers screened, prevalence of reported social needs, and use of social work resources.
During the 22-week study period, 147 caregivers were screened and 2 declined to participate. Thirty-four percent of caregivers endorsed ≥1 social need. The most common needs identified were depressive symptoms (23%), food insecurity (19%), and need for assistance with utilities (10%). All participants received information about the resource map, and 99% of caregivers with an identified need met with a social worker during their admission.
Using quality improvement methodology and technology, the team implemented a new standardized process for addressing social needs on an inpatient unit. This led to identification of social needs in more than one-third of caregivers screened and provision of resource map information to all caregivers. These findings reinforce the importance of standardized assessment of social needs in the pediatric inpatient setting. The role of technology, including resource maps and electronic health record enhancements, was highlighted.
Social factors in a child’s environment such as food access, housing stability, education, and exposure to violence are vital determinants of health.1–3 Health care providers have the opportunity to improve child and family health by addressing social needs at each interface with the health care system. Efforts to screen patients for social needs and connect families to community services have been effective in pediatric primary and urgent care settings,4,5 and previous studies have revealed that screening is feasible and acceptable in hospitalized patients.6–8 However, standardized methods for identifying and addressing social needs are generally lacking in pediatric inpatient care. Recent studies found that only approximately one-third of hospitalist and resident physicians regularly screened families for social needs in the pediatric inpatient setting.9,10 Barriers to screening included lack of time, lack of standardized screening tools, and lack of knowledge about the resources available to families.9 There is a need to establish tools and workflows that enable this enhancement to the delivery of inpatient health care.
Incorporation of technology into strategies to address social needs offers advantages for both patients and providers. There is evidence of patient preference and greater reporting of sensitive topics with electronic versus face-to-face screening.11–14 From the provider perspective, embedding screening in the electronic health record (EHR) can facilitate efficient screening and documentation of social needs.15 Higher screening rates16 and reduced bias13 are other potential benefits. Technology can also increase staff efficiency in responding to social needs, for example, by automatically generating resource guides based on identified needs.17 Web-based resource mapping Web sites, or searchable networks of community resources, are a novel use of technology to respond to social needs. Resource mapping Web sites allow not only staff to search for resources on behalf of patients but also enable patients to search independently, providing them with a locus of control in prioritizing their needs.18 Previous studies of patients with obesity and diabetes have demonstrated the feasibility of resource maps in clinical research and adult health care settings,18,19 but the study of resource maps in the pediatric inpatient setting remains limited.
In 2016, we formed an internal Intergenerational Family Services Workgroup to develop family-based care strategies. Systematic surveillance of social needs and expansion of community resource networks were identified as key strategies and became the focus of this project. We launched a quality improvement (QI) initiative aimed at developing and testing the feasibility of a workflow to identify and address caregivers’ social and emotional needs using a self-administered screening tool and a Web-based resource map with EHR integration on a pediatric inpatient unit. We aimed to screen 80% of families meeting eligibility criteria set for this phase of the project within 1 month of implementation and respond to 100% of caregivers with an identified need.
We conducted this project on 1 inpatient unit within an urban, academic pediatric hospital. The hospital serves children from local neighborhoods and surrounding counties, as well as children from other states or countries traveling for specialized care. The unit has 10 general pediatrics beds and 12 complex care service beds. The general pediatrics service provides care for a variety of infant and young child conditions such as viral bronchiolitis, gastroenteritis, and malnutrition. The complex care service targets medically complex patients with a variety of complex chronic conditions (CCCs) and includes NICU preterm infant graduates. The unit is staffed by attending physicians, resident physicians, nurses, and a social worker as well as 1 care team assistant (CTA) and CTA supervisor. CTAs support the work of the clinical service team on the unit by performing administrative tasks such as obtaining records, scheduling tests, and helping with preauthorizations.20
Planning the Interventions
We formed an advisory committee for this project composed of representatives from nursing, social work (SW), physicians, residents, CTAs, information services (IS), medical informatics, and population health, as well as from the hospital’s intimate partner violence (IPV) prevention program, food insecurity workgroup, and family advisory committee. Project charter, weekly meetings, literature review, key stakeholder interviews, and direct observation were used in the planning phase.
Before this initiative, there was no standardized social needs screening tool used in this inpatient setting. SW encounters occurred when requested by clinicians, as well as for all families admitted to the complex care service.
The major interventions were to develop an electronic screening tool, resource mapping Web site, EHR enhancements, and workflow for implementation.
In selecting relevant domains for inclusion in the screening tool, committee members prioritized the level of need in the patient population, availability of community resources, impact on health outcomes, and capacity of SW to respond to positive screens, while attempting not to duplicate processes already in place. After completing a prioritization matrix,21 food, transportation, utilities, caregiver mental health, and IPV domains were selected. To develop the screener, the committee adapted questions from the Centers for Medicare & Medicaid Services Accountable Health Communities screening tool1 and the Partner Violence Screen22 (Supplemental Table 4). The initial plan for screener administration was integration in the patient portal. However, we were unable to ensure that caregiver responses could be protected from other caregivers sharing access to the patient’s portal. Therefore, for this iteration of the project, the tool was programmed as a Research Electronic Data Capture (REDCap) survey23 and deployed by using electronic tablets.
The resource map Web site is a database of community-based organizations (CBOs) searchable by social need category and geographic location. Search results can be filtered by programmatic characteristics and preferences such as language spoken and hours of operation.
We contracted with a vendor, Aunt Bertha,24 to customize their resource mapping product (www.communityresourceconnects.org).25 In addition to Aunt Bertha’s process for identifying and vetting programs, hospital social workers were invited to submit preferred resources. The QI improvement advisor led focus groups of social workers in reviewing initial versions of the resource map to refine resources, filters, tags, and ordering of resources listed. The map was also adapted on the basis of feedback from families during pilot testing. Aunt Bertha performs ongoing resource map maintenance by immediate response to user feedback submitted through the site and biannual review of all resources. Hospital staff assigned to the resource map also perform updates.
Hospital IS partners made the resource map accessible through the EHR to facilitate staff searches on behalf of patients. IS also developed a check box for screener completion in the EHR’s SW navigator, which triggered an automatic statement about screener completion and resource map information on discharge paperwork for primary care providers and caregivers. Inclusion of this statement on the discharge summary was 1 method used to communicate with primary care providers about social needs.
We iteratively developed a process map to illustrate the workflow for incorporating the new tools (Fig 1). When establishing inclusion criteria for initial implementation, the multidisciplinary team prioritized safety in addressing identified needs, including IPV, before discharge. Therefore, for this phase of the project, we conducted screening only during weekday business hours when the unit social worker was available and the caregiver was physically present. Caregivers were screened as early in the admission as feasible. We excluded patients with an anticipated early (prerounding) discharge. Medically unstable patients with the potential need for transfer to intensive care were also excluded but became eligible for screening when their condition improved. Because the screener has not yet been programmed into other languages, only English-speaking caregivers were eligible for screening. The CTA explained the screening process to eligible caregivers at bedside. If the caregiver agreed to participate, the CTA provided a tablet for the caregiver to independently complete the screener but remained available to help if caregivers needed assistance. REDCap was programmed to send an automatic screener results notification to team members including the unit social worker and supervisor, CTA, and improvement advisor. If no social needs were endorsed by the caregiver, the CTA marked the screener as completed in the EHR. If a social need was identified, the social worker met with the caregiver to assess and provide guidance about available resources in their community, using the resource map. The social worker then marked the process as completed in the EHR.
In addition, we developed resource map business cards with a QR code and Web site address to be given to all families on the unit. The cards also included hotline numbers for poison control, postpartum depression, suicide prevention, and IPV. We programmed an automatic message with the national domestic violence hotline to appear on the tablet screen when IPV was endorsed.
Study of the Interventions
During weeks 1 through 3 of the project, (October 9, 2019, to October 29, 2019), we tested the workflow and screening tool with CTAs and ∼3 caregivers daily in a series plan-do-study-act (PDSA) cycles. In weeks 4 through 6, we gradually scaled the number of screenings performed until we reached our target goal. Our experience during small-scale testing led to several changes in the workflow including staff scheduling and refinements in screener design (Table 1).
We then implemented the revised interventions across the unit through week 22 (ending on March 13, 2020).
CTAs tracked the number of ineligible caregivers as well as the prevalence of each exclusion criteria in a REDCap database. CTAs also noted when caregivers needed help completing the screener because of literacy or technology issues. A team member (K.F.) extracted the number and duration of SW encounters for all screened patients. Demographic information, length of stay (LOS), admitting service, and CCC count were extracted from Epic for all patients admitted to the unit during the study period.
The primary measure was the proportion of eligible caregivers who completed the screener. To evaluate if patients screened were reflective of all patients admitted, we compared demographic characteristics of patients with and without completed screeners.
A primary outcome measure was identification of social needs, which we evaluated overall, by domain, and by demographic and patient characteristics (insurance type, medical complexity, admission service, and CCC as defined by Feudtner et al26 ).
We evaluated SW resources used to respond to positive screens. We compared patients with and without social needs identified on the screener with respect to the total number of SW consultations during the admission and duration of the SW encounter successive to screener completion. We also tracked the number of resource map searches each week. Of note, it is only possible to track the total number of resource map searches, inclusive of other searches by staff and caregivers elsewhere in the enterprise including the primary care network.
We evaluated the occurrence of caregivers identifying a social need on the screener and not receiving a response from the care team.
A run chart was used to evaluate screening rates over time. Descriptive statistics, as well as χ2, Wilcoxon rank, Fisher’s exact, and t tests, were performed by using Stata 12.0 (Stata Corp, College Station, TX).
This QI initiative was reviewed and determined to not meet the criteria for human subjects research by the hospital institutional review board. This publication was written according to Standards for Quality Improvement Reporting Excellence 2.0 guidelines.27
During the 5-month implementation period, there were 550 admissions, and 147 screeners were completed. Questions left unanswered were 1 of the 2 PHQ questions by 3 caregivers and IPV questions by 21 caregivers (Table 2). Two caregivers declined to participate and 57 were not English speaking. The remainder were not screened because of eligibility criteria established to avoid screening when the unit social worker was not available to respond to identified needs (admitted outside of SW hours, caregiver not present at the bedside during work hours, patient unstable or on early discharge list during work hours). Caregivers not being present at the bedside during screening times was a barrier that was addressed through PDSA cycles (Table 1).
Using the inclusion criteria set forth for this phase of the project, the unit achieved a high level of compliance with screening, as evidenced by a weekly mean screening of 93% across the implementation period (Fig 2) and multiple weeks with 100% of eligible patients screened. No caregivers who completed the screener required help because of technology or literacy issues; one caregiver requested help with typing because she was holding her infant. Mothers most often completed the screener (82.3%), followed by fathers (16.3%) and other caregivers (1.4%).
Demographic and clinical characteristics were compared between the 147 patients with completed social needs screener and the 403 patients without a completed screener. No significant differences were noted in sex, race or ethnicity. Median LOS was significantly longer in the screened versus nonscreened group (5 vs 3 days, respectively; P < .001). The prevalence of public insurance was higher in the nonscreened versus screened group (59% vs 40%, respectively; P < .001).
Of the 147 caregivers who completed a screener, 50 (34%) reported at least 1 social need (Table 2). The most commonly identified social needs were depressive symptoms and food (Table 2). Prevalence of any social need, positive depression screens, and utility needs were significantly higher on the complex care versus general pediatrics service (Table 2). There were demographic and clinical differences when patients with a reported social need were compared with patients without a reported need (Table 3). The former group had a higher prevalence of public insurance, Black race, and medical complexity.
The median number of resource map searches per week was 278 (range of 76 for week 1 to 663 for week 7).
We compared SW consultations between patients with and without a reported social need (Table 3). Although a majority of patients in both groups received SW consultations, patients with an identified social need had more. The median duration of the SW consultation immediately after completion of the screening tool was 15 minutes longer for the group of patients with an identified social need.
Of the 50 patients with a social need identified, only 1 patient did not have a subsequent documented SW consultation. The identified need was food insecurity, and discharge paperwork noted that the family received resource information through the resource map.
We used a QI approach to implement a social needs screener and resource map for families on a pediatric inpatient unit. Whereas before this initiative there was no standardized social needs assessment, 147 caregivers participated in an electronic self-administered screener during the 22-week project period. More than one-third of caregivers screened endorsed social needs, with depressive symptoms (23%) and food insecurity (19%) being the most common. The prevalence of food insecurity was consistent with previous estimates in our emergency department (21%).12 Comparison of social needs between complex care versus general pediatrics patients highlighted the importance of addressing social needs on the complex care service. An electronic resource map designed as part of this project was distributed regardless of screener results, and 99% of caregivers with an identified need consulted with SW. Within the parameters of inclusion criteria set to ensure in-person follow-up of identified needs, we achieved high and sustained screening rates.
In studying our process, however, we noted that overall, 27% of families admitted during the project period were screened, and public insurance was more prevalent in the group of patients not screened compared with the screened group. Requiring caregiver presence at the bedside during CTA and SW hours limited screening the most. We hypothesized that the requirement for caregiver presence may have limited participation not only overall but also disproportionately among economically disadvantaged families. The rationale for limiting screening to when the unit could respond in person was to avoid screening caregivers whose children could be discharged before their needs were addressed, which has been described as ineffective and arguably unethical.28 The criteria were also designed to prevent discharge of caregivers reporting IPV before establishing immediate safety and contact information for safe follow-up. The lessons learned informed our next PDSA cycles on process changes to safely expand inclusion criteria. At the start of the coronavirus disease pandemic, we developed a new workflow in which both screening and follow-up are completed virtually, so caregivers’ social needs could be addressed regardless of presence at the bedside during business hours. The knowledge we gained about the most prevalent social needs also allowed for the development of corresponding prepopulated resource lists. This work is ongoing.
A strength is that our work expands on previous inpatient social needs screening by also introducing a resource map. This novel approach addresses a common barrier to screening. A survey of pediatric hospitalists found that 83% would screen more if they had more resources to offer.9 We addressed social needs not only through screening but also by universally providing resource map information on cards with multiple hotline numbers, including an IPV hotline, to all caregivers regardless of screener results. This is important because previous studies have revealed that some caregivers who screen negative for food insecurity desire resources.29 Also, we hypothesize that some of the 12% of caregivers who opted out of IPV questions may have experienced IPV.30
Limitations include the inability to determine the number of resource map searches attributable to caregivers on the project unit. Translation of the screener into multiple languages is a priority because excluding non–English-speaking caregivers limited the number and diversity of participants. Of note, the resource map includes Google Translate functionality with >100 languages, so resource map information was still provided to families who did not meet the English-speaking eligibility criterion. We did not assess whether families successfully linked to CBO referrals. A future iteration of the resource map could allow for electronic tracking of resource use through closed loop communication with participating CBOs. Spreading this project to other units and institutions requires consideration that CTAs are not available on all inpatient units. Institutional investment in both staff engagement and technology to support staff efforts in addressing social needs is needed.
We implemented a streamlined workflow using technology to systematically and efficiently address social needs in a pediatric inpatient setting. High participation rates and prevalence of social needs support ongoing efforts to develop and refine tools and processes to address social needs as part of comprehensive health care provided to hospitalized children.
We thank Kristin Mcnaughton for her review of the manuscript. We thank Arleen Juca, Stuti Tank, and Kimberly St Lawrence for their work in implementing this QI project.
FUNDING: Funded by the Verizon Foundation. The Verizon Foundation did not participate in the work.
Dr Fortin participated in the project conceptualization, design, and implementation and drafted the initial manuscript; Drs Vasan and Scribano and Ms Wilson-Hall participated in the project conceptualization, design, and implementation and reviewed and revised the manuscript; Dr Rubin and Ms Brooks participated in the project conceptualization, design, and implementation and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.