From Incentives to Outcomes: A Framework for Implementing and Evaluating Social Needs Interventions

Addressing social determinants or drivers of health is key to improving child health outcomes and promoting health equity, but it remains unclear how pediatric hospitals can most effectively identify and address families’ social needs. In recent years, the National Academy of Sciences, the Joint Commission, the National Commission for Quality Assurance, and the Center for Medicare and Medicaid Services have all issued guidelines or requirements that support and incentivize social care integration, including quality measures around social needs screening and intervention.^1,2  As a result, a growing number of hospitals have rapidly implemented social needs screening and referral programs. It is, therefore, critical to establish robust standards and metrics for evaluating these programs aimed at assessing and addressing families’ unmet social needs, so that less successful interventions can be iteratively improved, and more successful interventions can be expanded and scaled with sustainability.

In this month’s issue of Hospital Pediatrics, Pantell and colleagues analyzed responses to the 2020 American Hospital Association Annual Survey of children’s hospital Chief Executive Officers (CEOs) to estimate the national prevalence of social needs screening and interventions.³  The authors found that although most children’s hospital CEOs reported that their institutions screened for and addressed at least 1 social risk, approaches to social risk screening and intervention varied significantly. Additionally, although a minority of hospitals reported assessing the effectiveness of their social needs interventions, CEOs at more than one-half of these hospitals reported that their efforts led to improved outcomes.

To our knowledge, in this study, Pantell et al present the first benchmark of social care practices at children’s hospitals nationally. This work leverages a well-studied survey to offer both a valuable gross estimate of current practices and an easily replicable measurement strategy that could be redeployed in the future to monitor social needs screening trends. Unfortunately, this approach has considerable limitations. Most critically, CEO-reported data may not accurately represent the status of inpatient social risk-related practices. Because hospital CEOs often oversee care delivery across multiple clinical settings, we cannot guarantee that these responses are reflective specifically of inpatient practice, especially with burgeoning social care efforts in the outpatient and emergency department settings across the country.⁴  Additionally, because there was no requirement for CEOs to verify their responses by providing details of their hospitals’ social needs screening practices, there is no way to ensure the internal validity of survey responses. CEO responses may also have been influenced by social desirability bias, given the considerable interest in social needs screening among regulatory and professional organizations.

With emerging incentives and requirements on the horizon, hospital administrators may feel continued pressure to rapidly implement social needs screening to comply with these expectations. However, we believe that there are several key factors that health system administrators should take into consideration to ensure that interventions are implemented in a way that is feasible, sustainable, family-centered, and ultimately effective in resolving families’ needs.

First, standardizing screening practices across all institutions and care settings may not be the answer. Pantell and colleagues highlight the great degree of variation in screening practices nationally, especially related to the specific domains included in screenings. This is likely out of necessity because social needs screening should ideally be adjusted to fit each specific hospital’s workflow and patient population. Although there are a wide array of social needs screening tools available, these tools differ in the domains they explore, and only a select few evaluate patients’ interest in assistance for identified needs, which has been shown to increase the rates of successful referral and resource connection.^4,5  Additionally, validated screeners may differ in their positive predictive value across care settings because the prevalence of individual social needs can vary considerably in different populations.⁶  Relevant social needs screening domains may also differ across settings and patient populations; for example, it may be particularly important to screen hospitalized families for food insecurity in the inpatient setting, or to screen caregivers of children with technology dependence for their ability to pay for utilities. Hospital administrators should, therefore, consider their patient population and the needs identified in their community health needs assessments when considering how to adapt existing screening tools to best fit the needs of their populations.

Second, decisions about screening for unmet social needs must be informed by the availability of resources to address positive screens. Only 67% of hospitals in this study reported existing strategies to address all domains for which they screened. This is an alarming finding. Although there is certainly value in better understanding families’ social contexts to guide their medical care, this must be artfully done to respect boundaries and preserve the physician-patient relationship.^7,8  Screening for unmet social needs without providing appropriate resources could lead to frustration and distrust among patients and families.⁹  Thus, in line with best practices, hospitals should prioritize screening for needs that they have the capability to address.^10,11 

Another significant barrier to the standardization of social needs interventions across institutions and care settings is that the resources available to families can vary substantially based on geography, over time, and across patient populations.¹²  Federal government benefit programs like Medicaid and the Supplemental Nutrition Assistance Program are typically administered at the state level, with each state implementing unique eligibility criteria and enrollment processes. Similarly, community-based organizations addressing specific social needs may not be available in all geographic settings, and in areas in which these organizations are available, they may still vary considerably in the extent of services they provide and in their populations of focus. Resource availability fluctuates with time, based on policy changes and fluctuations in funding, as seen with the transient surge of community-organized and government-sponsored resources as a response to the increased burden of social needs during the severe acute respiratory syndrome coronavirus 2 pandemic.¹³  Some subpopulations of families with unmet social needs, such as those who speak languages other than English or live in households with mixed immigration status, may need extra support in identifying community-based resources and organizations that are accessible to them and can meet their unique needs.⁸  These are particularly significant barriers to designing standardized social needs interventions at tertiary and quaternary care children’s hospitals, which often have catchment areas that cross city and state borders and serve diverse, heterogeneous patient populations.

Finally, as we monitor new social needs programs for effectiveness, we must critically reevaluate how we measure success. This study assessed whether health systems measured effectiveness based on improvement in health outcomes, which is one primary goal of health care-based social interventions. Although only 39% of hospitals in this study assessed the effectiveness of strategies to address social needs, of these, more than one-half of CEOs noted improved health outcomes, decreased health care utilization, or decreased costs as a result of their interventions. As the authors note, this finding is particularly surprising because there is a dearth of literature on the health outcomes of social care practices. Given the chronic nature of many social determinants of health, we may not be able to see the full health impacts of social interventions for years or even decades, particularly for interventions focused on early childhood.

Before we jump to measure these more distal outcomes, we should be carefully assessing some key proximal and process-oriented measures. Take, for example, Kirkpatrick’s Four-Level Model. This work has been used for decades to guide the evaluation of medical education strategies, assessing students at different stages of their learning, from educational experience to ultimate clinical performance.¹⁴  Here, we adapt this model to propose a framework to evaluate health systems’ social interventions (Fig 1).

Just as curricula should be created with each of these steps taken into consideration, social interventions should be designed with the same process in mind. To effectively produce our desired health outcomes, we must ensure our strategies are supported by families, facilitate feasible connections to resources, and ideally result in the resolution of identified needs. If health systems identify areas in which existing resources are inadequate to meet families’ needs, they should use targeted community benefit spending to bolster the availability of community-based resources and engage in advocacy focused on strengthening social service programs targeted to these needs.

There is a growing body of literature exploring family perceptions of inpatient social needs screening and response strategies that has revealed overall support for different approaches.^8,15–17  However, there is limited work published on measuring resource connection and need resolution. Analyzing implementation strategies that support these next-level outcomes stands as the opportune next phase of research on social care practices. With institutions across the country implementing social needs screening strategies in response to new incentives, measuring key outcomes at each of these levels could help improve programs’ efficacy and support program sustainability.

Although new incentives give credence to much-needed work around addressing social determinants of health, we should not rush to the finish line. As we continue to benchmark our progress into the future, a thoughtful, interdisciplinary adaptation of evidence-based screening and intervention practices, with systematic assessment of process and outcome measures, will be key to achieving improved and more equitable child health outcomes.