What Should Hospitalists Consider in Addressing Social Determinants of Health? Free

With 6 million children hospitalized annually,¹  pediatric hospitalists can serve a critical role in improving population health by screening for adverse social determinants of health (SDoH). Children who face adverse SDoH at baseline have disproportionately higher hospitalization rates,^2,3  and adverse SDoH can also negatively affect children during and after their hospital stay, propagating disparities in readmissions, length of stay, cost, and medical errors.^3,4  As such, hospitalization is an opportunity to connect families to vital resources, particularly for those with limited outpatient supports (eg, children without a consistent primary care provider).

In this issue of Hospital Pediatrics, Lopez et al share the results of a randomized controlled trial evaluating a comprehensive approach to screening for SDoH in hospitalized children.⁵  In the study, although both groups had a basic assessment of social risk, only the intervention group received additional comprehensive screening based on the outpatient WE CARE study⁶  covering 20 basic needs. Intervention families who screened positive for any of the included concerns received an indirect referral, a “1 pager” with resource program name, brief description of the program, and contact information, along with a 2-week follow-up call to confirm receipt of the resource document. Families that screened positive for housing, intimate partner violence, mental health concerns, and/or substance abuse also received a social work consult. Both groups also received a 6-month follow-up call to assess self-reported resource enrollment, barriers to enrollment, and child health indicators. For the primary outcome, which was enrollment in a new community-based resource at the time of the 6-month follow-up call, the investigators found no difference between the groups (∼52.5% enrollment in additional resources). The resourced families in the study enrolled in most often included a new primary care provider for any family member, health insurance for a family member, or food resources.

The results of this randomized trial showcase the potential of inpatient SDoH screening and the potential benefit of referrals. The study took place in a population with a high baseline prevalence of social needs in the study population (85% with ≥1 social risk) and high rates perceived stress among participants. Although these factors, for many reasons, should have made enrollment a challenge, the study team achieved reasonable enrollment (75%) and 6-month follow-up rate (72% of enrollees). This suggests that comprehensive screeners such as the WE CARE tool can be deployed in the inpatient setting. This is welcome news, given that prior work in pediatric outpatient settings has shown that SDoH screening can increase referrals to community resources, improve adherence to preventive care (eg, vaccinations), and result in fewer social needs in subsequent visits.^7–9  However, although many inpatient providers are aware of the link between adverse SDoH and suboptimal postdischarge outcomes, they do not routinely screen for these risks during acute hospitalizations.²  This study begins to address key gaps in our ability to identify and begins to address adverse SDoH during hospitalization because there are limited data on best practices for screening, referral, and follow-up.

It is also important to consider how the study approach may have influenced the results of this trial. The study team used a convenience sample of patients recruited during daytime hours (3–7 pm weekdays, 9 am–2 pm on weekends), which means they may have missed parents who were at work or caring for other family members during those times. Although recruiting a convenience sample is reasonable for a pilot study, it does not appear that the authors collected any demographic data on patients they were unable to enroll, so it is unclear if this convenience sample represents the overall population. They also recruited on day 3 or later of admission, which is longer than the median length of stay for their patients. Additionally, the study was limited to include only mothers instead of any caregiver at the bedside. The 52.5% referral enrollment rate, which was similar for the 2 study arms, may well be related; the authors postulate that there was lower efficacy for indirect (resource information given to parents) compared with direct or so-called “active” referrals (parent contact information provided to referral site or referral placed during hospitalization).

Previous studies have demonstrated acceptability of SDoH screening in acute care settings such as a hospitalization as well as success using direct or active referrals from both outpatient and inpatient settings to community resources.^10–13  And although the opportunity for standardizing and increasing the rate of SDOH screening in the inpatient setting is clear, the evidence from other settings on how such practices may affect subsequent health outcomes, and whether higher intensity strategies such as direct referrals are more effective, is mixed. One study conducted in pediatric primary and urgent care departments found that connecting families with a navigator decreased social needs and improved child health.⁶  Another pediatric urgent care–based study demonstrated no difference in social risk or child health effects between families who received a written resource compared with those who received a written resource and in-person assistance.¹⁴ 

The findings from the Lopez et al study adds to this evidence by demonstrating no difference in referral enrollment. This may suggest that barriers to enrollment are complex, but also that there are multiple pathways by which families become connected with resources. Future studies could explore this further, along with assessing the acceptability, appropriateness, and feasibility¹⁵  of a proposed intervention to best understand the highest priority aspects of these interventions from the family perspective, and to better describe structured ways to implement these approaches in a busy clinical setting where there may be competing priorities.

This study has identified 1 potential approach to screening and referral that could be adapted and studied in larger trials; this could help us move toward a more standardized approach to screening and acting on SDoH identified during hospitalization. As important as randomized trials are for understanding the impact of interventions, there are also pitfalls in pursuing this work without ongoing and deep engagement from families and community members. For example, it is possible for some families that screening without direct or active referrals to resources may cause family discomfort or distrust because they have disclosed sensitive information to someone without the tools to do anything about it. The findings from Lopez et al suggests there could be a potential concern here, given there was no increase in resource enrollment for the intervention group. For some families, indirect referrals may not result in increased enrollment in community resources; families may benefit more from active referrals or connections to community resources and/or closing the loop with the patient’s primary care provider or medical home. This may be of particular importance to those families that may not be able to be present during rounds or during hospitalization.

Given the effort involved in active referrals, future studies should consider evaluating the health benefits compared with the resources, financial and otherwise, involved in providing active or direct referrals from the patient and health system perspective. Important, too, will be rigorous engagement work aimed at delineating processes for ensuring community- and hospital-based processes for referrals are well aligned. This type of work could be instrumental in informing policy decisions that may promote broad diffusion and uptake of evidence-based screening practices. However, the varying quality, capacity, and setup of community resources may also influence enrollment rates, independent of screening and referral process. Hybrid implementation-effectiveness trials¹⁶  are 1 approach that could lead to a deeper understanding of the different contextual factors influencing resource enrollment, allow the rigorous measurement of patient-centered and patient-reported outcomes, and promote the development of inpatient screening strategies that can ultimately be broadly adopted in all inpatient settings that provide care for children.