Promoting Health Equity Through Family-Centered Social Needs Screening and Intervention in the Inpatient Setting

Poverty and associated health-related social needs, such as food insecurity and housing instability, can limit children’s access to care and adversely affect child health outcomes.^1–3  Addressing social needs should, therefore, be a priority for pediatric clinicians and health systems serving low-income children and families.⁴  Many pediatric primary care clinics have implemented social needs screening programs over the past decade, and a growing number of hospitals and health systems are now also incorporating screening in the inpatient setting.^5–7 

Inpatient social needs screening and referral programs may be a beneficial adjunct to primary care–based programs because they allow health systems to reach patients and families who have limited access to primary care. In addition, children’s longer length of stay in the inpatient setting may allow more time for a comprehensive assessment of families’ needs and preferences, and some hospitals may have additional resources available to address families’ needs, such as on-site social workers and case managers. However, unlike in the outpatient setting, families do not typically have longitudinal relationships with their inpatient care teams, meaning building and establishing trust can be more challenging. It is, therefore, critical to consider families’ perspectives in determining how social needs screening and referral programs should be implemented in the inpatient environment.

In this month’s issue of Hospital Pediatrics, Leary and colleagues present the results of 17 qualitative interviews with caregivers at both a tertiary care and a community pediatric hospital regarding inpatient social needs screening.⁸  These interviews were conducted with both English- and Spanish-speaking caregivers who were predominantly Medicaid-insured and explored parent and caregiver opinions on the utility of screening across multiple health care settings, their comfort discussing social needs with hospital providers, and their preferences for screening in the inpatient environment. Their work represents an important contribution to the literature on this topic.

Leary et al highlight several key findings. First, caregivers appreciated screening across multiple care settings and viewed hospitals as capable systems to respond to social needs. Second, caregivers expressed concerns about screening in the presence of their children, other family members, or families in shared rooms. Third, caregivers wanted to be able to express their preferences regarding documentation of social needs and whether and how this information was shared with other providers.

The concerns expressed by caregivers in this study should serve as a caution to all institutions implementing inpatient social care interventions. These programs must be designed to be family-centered, prioritizing families’ safety, autonomy, and dignity, and ensuring hospitals have the capacity to partner with community-based organizations to address identified needs.

Hospitalists interested in developing social care interventions should begin by partnering with key stakeholders who have expertise in understanding and addressing families’ needs, including social workers and community-based organizations. They should also consider conducting a local needs assessment, similar to Leary et al’s study, to understand the unique perspectives and preferences of parents and caregivers with unmet social needs in their setting.

When implementing screening, hospitals must develop a standardized process that ensures privacy. Although caregivers interviewed by Leary et al felt comfortable with verbal discussions, they also reported a strong preference for having these conversations privately. Given this preference, and existing literature showing increased disclosure rates when screening is conducted on tablets,^9,10  we suggest tablet-based screening or paper-based screening when tablets are unavailable. It is often impractical to conduct verbal screening privately in the inpatient setting, in which there is almost always a child present in the hospital room and may even be another family sharing the room. To reach families with limited literacy or with emerging English proficiency while preserving this privacy, hospitals could also offer the option of audio assistance with screening, including assistance from a medical interpreter, using hospital-provided headphones. Screening tools should ideally ask both about families’ needs and about their desire for assistance, because not all families who screen positive for a need may desire help, and some families who screen negative may still appreciate and benefit from resources.¹¹ 

Hospitals also need to develop clear protocols to ensure social needs are documented in a way that prioritizes families’ safety and dignity. Particularly in the era of the 21st Century Cures Act, when patient information is more readily available to patients and their proxies, documenting the results of positive screens in the electronic health record could pose challenges. One particularly concerning scenario to consider is a caregiver’s disclosure of intimate partner violence: if this information is documented in the electronic health record without the appropriate precautions, their disclosure may be visible to their partner and thereby pose an immediate safety risk.

Screening programs must also consider whether and how social needs will be shared beyond the inpatient environment. We suggest engaging in shared decision-making with families on whether they would like information shared with their child’s primary care doctor or other providers with whom they have an established relationship. Some caregivers, particularly those of medically complex children, may also need longitudinal support in resolving their needs.¹²  Hospitals should have a plan in place for how these needs can be communicated to primary care providers, case managers, outpatient social workers, or community health workers when families express that this is their preference.

Additionally, screening and referral processes must always be implemented with an explicit focus on promoting health equity. This should involve tracking of equity-focused metrics, including, at minimum, rates of screening, referral, and resource connection stratified by race, ethnicity, and insurance status. In our own inpatient social needs screening work, we found that we had unintentionally created a disparity in screening rates on the basis of insurance status, with lower rates of Medicaid-insured caregivers being screened, because we were only screening caregivers who were present in the hospital between 9 am and 4 pm on weekdays.¹³  We were subsequently able to achieve improved parity in screening rates by incorporating text message–based screening for families who were not able to be at the bedside during the day because of work, child care, or other obligations.

A focus on health equity also involves eliciting the perspectives of families with unmet social needs and families with a preferred language other than English. Leary et al interviewed families who were predominantly Medicaid insured but did not ask about unmet social needs, and it is possible that the subset of these families with lived experiences of food insecurity, housing instability, or other social needs may have had slightly different perspectives. Leary et al included 2 Spanish-speaking caregivers in their interviews, which is commendable; however, additional input from families with limited or emerging English proficiency will be critical to ensure that social needs screening and referral programs can meet their unique needs and do not compound existing language-based disparities in awareness of and access to resources.

Finally, before implementing screening, hospitals must have a clear workflow in place for helping families connect with resources. Screening without adequate resources can create what some families have described as a “double loss,” in which the disclosure of sensitive information regarding their needs is a first loss, and not getting help with their identified needs is a second loss.¹⁴  Thus, screening without the ability or infrastructure to provide help risks inducing trauma, engendering mistrust, and alienating families.^15,16  Hospitals must, therefore, be able to connect families who would like help with available hospital- and community-based resources. Hospitals serving a large catchment area must consider how they might identify local community-based resources for families living farther away.

Searchable electronic resource maps represent 1 promising strategy for helping families identify locally available resources, but providing a link to a resource map Web site alone may be insufficient to ensure families can connect with these resources.^12,17  In addition, because effective social needs screening and referral depends in part on the availability of a robust social safety net, nonprofit hospitals should consider using their community benefit spending to invest in and strengthen the resources available to families in their surrounding communities, and pediatricians should advocate for state and federal policies that improve existing government benefit programs and increase families’ access to benefits.^18,19 

Upcoming Centers for Medicare and Medicaid Services regulations that suggest making inpatient social needs screening a quality measure represent an important recognition of the relevance of these factors to health and well-being.²⁰  However, these regulations risk doing more harm than good if screening is incentivized without concurrent investments in the infrastructure needed to support families with unmet needs and without a thoughtful understanding of how social risk assessment and interventions should be optimally implemented in the inpatient setting. Leary et al’s study is an important step toward this improved understanding. It is only by partnering with experts with lived experience, including parents and caregivers with unmet social needs and the social workers, community health workers, and community-based organizations that are most experienced in addressing these needs, that we can hope to implement equitable, effective, and family-centered social care interventions in the inpatient setting.