Advertisement

Moving From Social Risk Assessment and Identification to Intervention and Treatment

Published:January 11, 2016DOI:https://doi.org/10.1016/j.acap.2016.01.001
      Clinical care seeks to match the right patient to the right treatment. Clinicians use histories and physicals to guide assessment and to determine diagnosis and management plans. This pattern of assessment, identification, and treatment typically focuses on symptoms and diseases. However, mounting evidence suggests that social determinants of health (SDH) may be just as, if not more, relevant to clinical outcomes than many of the medical or biologic determinants that often dominate our focus. It is therefore natural to consider how we might reliably and effectively integrate assessment, identification, and treatment of the SDH into clinical practice.
      The SDH are upstream factors, frequently rooted in poverty, that underpin gradients in health outcomes. Evidence suggests that interventions eliminating or at least mitigating the harmful effects of risks related to the SDH place children on more positive lifelong trajectories.
      • Braveman P.
      • Egerter S.
      • Williams D.R.
      The social determinants of health: coming of age.
      This represents a crucial opportunity to optimize how we identify social risks and then connect children experiencing those risks to potentially life-changing interventions. Although many actionable, family-centered social risk screens have been developed, studies that compare their effectiveness are few. Moreover, linkages between identified risks and SDH-targeted care algorithms must be operationalized and evaluated.
      This edition of Academic Pediatrics contains 3 articles
      • Kerker B.D.
      • Storfer-Isser A.
      • Szilagyi M.
      • et al.
      Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • Collie-Akers V.
      • Chung P.J.
      Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • et al.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      highlighting different aspects of social risk assessment and identification with some, but more limited, attention paid to the critical next step: treatment. Kerker et al
      • Kerker B.D.
      • Storfer-Isser A.
      • Szilagyi M.
      • et al.
      Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
      assessed the frequency with which pediatricians screen for adverse childhood experiences (ACEs), which include childhood abuse, neglect, and household dysfunction. They surveyed a random sample of American Academy of Pediatrics members. Although results were limited by a relatively low response rate, the authors found that one-third of pediatricians reported that they do not routinely ask about any ACE. Very few use standardized social screening tools, and many have never heard of ACEs and their link to suboptimal health outcomes despite recent American Academy of Pediatrics recommendations encouraging universal assessments.
      • Kerker B.D.
      • Storfer-Isser A.
      • Szilagyi M.
      • et al.
      Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
      Clearly, efforts directed at increasing the frequency and reliability of screening are needed. A more uniform approach to screening that highlights the most effective aspects of various tools, using both linkages to resources and health as measured outcomes, would also be beneficial.
      • Garg A.
      • Toy S.
      • Tripodis Y.
      • Silverstein M.
      • Freeman E.
      Addressing social determinants of health at well child care visits: a cluster RCT.
      Many pediatricians who do not routinely screen think that social risk questions go beyond the scope of the clinician.
      • Kerker B.D.
      • Storfer-Isser A.
      • Szilagyi M.
      • et al.
      Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
      Such concerns may be unfounded. In a cross-sectional study of caregivers of hospitalized children, respondents overwhelmingly voiced positive opinions of physician screening for unmet social needs. Indeed, Colvin et al
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • Collie-Akers V.
      • Chung P.J.
      Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.
      report that >70% of caregivers feel their child's doctor should ask about issues such as income, insurance, housing, food insecurity, educational needs, intimate partner violence, immigration, and guardianship. This increased to >85% if caregivers reported having been previously screened.
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • Collie-Akers V.
      • Chung P.J.
      Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.
      This should dispel notions that screening, if performed appropriately, is taboo.
      Meeting families where they are may mean asking sensitive questions across inpatient and outpatient care environments. In a separate article, Colvin et al
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • et al.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      used a brief educational intervention to increase rates of inpatient social risk assessment and identification, an intervention that may have applications in other health care settings. Pediatric residents on their intervention team were 3 times more likely to identify risks and refer their patients to a social worker—a potentially important first step. Assessments of how this educational intervention and the resulting social work referrals mitigate identified risks and ultimately affect health outcomes is critical to establish the importance and reach of such activities. Additional evaluation of the approximately 10% of families that had active needs but that were unable to be connected with referrals or resources may illustrate the ramifications of missing the opportunity to connect risk identification to risk management.
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • et al.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      Although getting to such treatment or management is essential, the challenge of merely identifying social risks should not be understated. It is one thing to routinely ask families about social risks; it is another to ask in an empathetic, family-centered way. This can be a learned skill, much as junior clinicians learn to distinguish pathologic from physiologic heart murmurs. Like many of these skills, one's ability to detect pathology may deteriorate over time, especially if not practiced continually.
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • et al.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      “Booster doses” of educational interventions may be required alongside development of processes that make action as easy as possible (eg, weaving assessments and decision support into electronic health records). Objective evaluation of clinicians, including the delineation of entrustable professional activities, may be needed as we seek to ensure that trainees are able to identify social pathology and develop appropriate assessments and plans just as they would medical pathology.
      • Klein M.D.
      • Schumacher D.J.
      • Sandel M.
      Assessing and managing the social determinants of health: defining an entrustable professional activity to assess residents' ability to meet societal needs.
      Ultimately, social risk assessments should be action oriented, with identified risks readily connectable to risk-targeted treatments. Much as we do not end a clinical encounter by merely stating that a child has screened positive for lead poisoning, so too should we not end an encounter by highlighting the presence of a social risk; managing that risk is paramount. Although health system–based partners like social workers are incredibly valuable,
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • et al.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      additional partners (and interventions) may need to be community based. Partnerships with entities such as legal aid societies, food banks, and other nonprofit agencies can extend the reach of the clinician, providing the necessary SDH-related expertise.
      • Henize A.W.
      • Beck A.F.
      • Klein M.D.
      • Adams M.
      • Kahn R.S.
      A road map to address the social determinants of health through community collaboration.
      Partnership development, although challenging, is a vital step toward effectively treating patients and families. We should also strive to build linkages to community resources into routine care processes, such that referrals to attorneys (ie, SDH-risk subspecialist) can be made as simply as referrals to cardiologists.
      Clinicians are taught to diagnose and treat pathology to improve the health of patients and the broader community. Diagnosing and treating social pathology alongside medical pathology is necessary if we are to achieve desired outcomes. We therefore must develop a means through which highly trained, empathic clinicians perform assessments for and identify social risks efficiently and reliably. We must then push ourselves to move from risk assessment and identification to treatment, determining how preventive, community-focused service provision across care environments affects child health and well-being. Social risk management, including assessment, identification, and ultimately treatment, has never been more relevant as clinicians, health systems, and communities seek lasting improvements to patient and population health outcomes.

      Acknowledgments

      We thank Robert Kahn for his critical review of this commentary. Supported in part by the National Institutes of Health (NIH 1K23AI112916 ; PI: Beck). Funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Received for publication January 6, 2016; accepted January 7, 2016.

      References

        • Braveman P.
        • Egerter S.
        • Williams D.R.
        The social determinants of health: coming of age.
        Annu Rev Public Health. 2011; 32: 381-398
        • Kerker B.D.
        • Storfer-Isser A.
        • Szilagyi M.
        • et al.
        Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
        Acad Pediatr. 2016; 16: 154-168
        • Colvin J.D.
        • Bettenhausen J.L.
        • Anderson-Carpenter K.D.
        • Collie-Akers V.
        • Chung P.J.
        Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.
        Acad Pediatr. 2016; 16: 161-167
        • Colvin J.D.
        • Bettenhausen J.L.
        • Anderson-Carpenter K.D.
        • et al.
        Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
        Acad Pediatr. 2016; 16: 168-174
        • Garg A.
        • Toy S.
        • Tripodis Y.
        • Silverstein M.
        • Freeman E.
        Addressing social determinants of health at well child care visits: a cluster RCT.
        Pediatrics. 2015; 135: e296-e304
        • Klein M.D.
        • Schumacher D.J.
        • Sandel M.
        Assessing and managing the social determinants of health: defining an entrustable professional activity to assess residents' ability to meet societal needs.
        Acad Pediatr. 2014; 14: 10-13
        • Henize A.W.
        • Beck A.F.
        • Klein M.D.
        • Adams M.
        • Kahn R.S.
        A road map to address the social determinants of health through community collaboration.
        Pediatrics. 2015; 136: e993-e1001

      Linked Article