Forging a Path to Effective Inpatient Health-Related Social Needs Screening and Response

Health-related social needs (HRSNs) screening and response are critical components of the delivery of comprehensive patient care. Furthermore, pediatric hospitalization is an opportune and yet underleveraged time to identify and mitigate social risk factors and needs and potentially improve the transition from hospital to home. The gradual adoption of alternative care delivery and value-based payment models in pediatrics in addition to recommendations from entities like Centers for Medicare and Medicaid services and Joint Commission^1,2  have contributed to the increased focus on identifying and addressing HRSNs across all phases of care, including hospitalization.

HRSNs are common among hospitalized children and their families, making the case for social care integration in the inpatient setting.^3,4  Leary and colleagues conducted a pre-post implementation study to evaluate the impact of a universal, standardized HRSNs screening and referral system in a community hospital.⁵  More specifically, the authors compared outcomes after the implementation of a stakeholder-informed social care program^6,7  to outcomes from usual care before introducing the implementation strategy. The outcomes of interest were (1) social risk screening rates across 6 domains, (2) identified social risks, (3) completed social work consults, (4) community resource referral rates, and (5) communication of social risks in discharge summaries. The authors noted increased screening rates for social risk across all domains, more frequent and timely social work consult completion, and increased documentation of social risks in a random subset of discharge summaries among the postimplementation group (n = 218) compared with the preimplementation group (n = 232).

Leary and colleagues’ work highlights several important factors relevant to the successful implementation of a social care integration model in the pediatric inpatient setting. First, their study builds on efforts to develop a social integration model informed by partners including frontline staff and parents of hospitalized youth.^6,7  Qualitative results from parent interviews in this formative work reinforced the importance of HRSN screening, parent perceptions of hospitals as capable systems to respond to social needs, parent comfort discussing social needs with frontline staff, and the importance of empathy and family-centered approaches to HRSNs screening. The authors included 6 items on the social risk screening instrument each associated with 1 of 6 domains (food, housing, education, finances, transportation, and safety) that was determined by a multidisciplinary team. Their decisions were influenced by a desire to develop a screen for social risk factors that directly impact youth and could realistically be addressed in the inpatient setting. The authors were able to embed the screening instrument in the electronic health record and leverage the nurse intake process on admission to implement person-to-person screening.

The study by Leary et al also illustrates the real challenges with implementing a robust HRSN screening and response model. Barriers to effective screening include: (1) determining the owners of the screening process (eg, clinicians, nurses, social workers); (2) competing priorities, such as patient acuity, and volume on frontline staff engagement; and (3) difficulties finding a reliable screening process that is both standardized and customizable to meet the unique needs of hospitalized youth and families (eg, having interpreters available for verbal screening or translated copies of screener for families that speak a language other than English [LOE]). Leary et al leveraged the existing nursing workflow during admissions and implemented a nurse-reliant screening process, though this approach may not be feasible or realistic in other health care institutions.

Additionally, it is important to consider the findings from previous studies that illustrate the benefits of parents and caregivers completing screening instruments on their own without direct inquiry from frontline staff.⁸  The 21st Century Cures Act Office of the National Coordinator for Health Information Technology Rule⁹  has accelerated the use of patient portals and smartphone health applications for completing intake forms, sharing resources, and facilitating communication between patients, families, and providers. Several tools (tablets, kiosks, and web-based platforms) have also been used to facilitate HRSN screening processes that are not reliant on frontline staff directly asking parents and caregivers questions. Evidence suggests higher rates of positive screens with this approach, showing increasing disclosure rates of sensitive or stigmatized issues that may otherwise go unreported by families if asked directly.⁸  However, the integration of technology in health care has also contributed to inequities.¹⁰  Technology advances and innovations primarily cater to those whose primary language is English and exacerbates communication barriers for more than 67 million individuals aged 5 years and older in the United States who speak an LOE.¹¹  To address these inequities, health care systems must reliably provide alterative screening modalities for LOE families and other relevant populations. This approach will likely need to continue until electronic health records and health applications become more equitable and inclusive.

Moreover, hospitals must couple the design and implementation of HRSN screening with a robust and reliable response system. Screening without a plan and/or the capacity to address identified social needs may diminish trust between families and the health care system. Response to identified social needs in the inpatient setting may include passive (eg, distribution of handout with community resources to families) or active interventions (eg, social work consultation, direct connection to food pantry resources to mitigate food insecurity). Leary et al demonstrated a positive association between HRSN screening and social work consults. The team included social workers as core members of the multidisciplinary team who designed the intervention. Although a robust response structure should include strong partnerships with social workers in the inpatient setting, their capacity to handle increased consult volumes may vary across institutions; hence, attention to social work capacity must be part of the intervention design phase. Leary and colleagues also implemented a process by which families received information about resources based on their identified social needs and referrals were documented in discharge summaries. Although passive sharing of information and placing referrals should be a part of an HRSN screening and response algorithm, it cannot be the sole approach.¹² 

Identifying community resources that span the geographic region of the population served is essential for ensuring that the HRSN screening and response process is both effective and equitable. Health care systems must engage and build strong relationships with community partners to understand the landscape of resources and support and best meet the needs of their patient population. Hospitals should collaborate with local businesses, nonprofit organizations such as foodbanks and faith-based organizations, schools, and other child welfare or social service entities to create a comprehensive network of support that provides a range of services like food, housing resources, legal aid, and specialized care such as parental mental health support.

Furthermore, although challenging, it is important to establish a learning system in which families can report on the utility and accessibility of the referred services. This feedback can be used to continuously improve the referral system, ensuring that it remains responsive to the changing needs of the community. By taking a proactive and patient- and family-centered approach, health care providers can build trust and foster a sense of community partnership, ultimately leading to better health outcomes and a reduction in health inequities.^13,14 

Health care institutions have a mission to deliver quality health care that requires identifying and addressing the social conditions that impact pediatric health outcomes. Hospitals across the United States are at various stages of planning, implementing, or evaluating their current approach to HRSN screening and response. Although this task may seem daunting, strategic planning and investment can significantly increase the likelihood of successfully implementing an integrated social care program. Health care institutions should (1) ensure their workforce is educated on the impact of social determinants of health on pediatric outcomes, (2) assess their current state of HRSN screening and response, (3) collaborate with internal and external partners that can contribute to HRSNs screening and support, and (4) take an evidence-based and equity-oriented approach to HRSN screening and response. By assessing capabilities realistically and prioritizing actions aligned with available resources and goals, we can make meaningful progress toward addressing HRSNs of hospitalized youth.