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Address correspondence to Lauren AH VonHoltz, MD, MPH, Pediatric Emergency Medicine, The Children's Hospital of Philadelphia, Colkett Translational Research Building, 3501 Civic Center Blvd, 2nd Floor, Philadelphia, PA 19104
Recognizing the need for enhanced social care integration in the emergency department (ED), the unique position of the ED for expanding social risk interventions as it serves as a point of care entry, and the potential power of ED staff working remotely, an interdisciplinary group of physicians nurses and social workers created an innovative virtual social resource referral program, “Family Connects,” within the ED of a large, metropolitan freestanding children's hospital.
This report reflects on the first year of the program.
Innovation and Context
Family Connects is an interdisciplinary initiative that assists families with social needs at the point-of-care in the Children's Hospital of Philadelphia (CHOP) ED. In 2020 this ED saw 50,788 unique patients over 68,782 encounters; 54.8% were African American, 11.5% Latino; 5.9% were non-English speaking, and 57.4% Medicaid insured. Program representatives call the room phone or cell phone of caregivers arriving with pediatric patients to the ED weekdays between 9a-11p during their ED visit. Families are eligible if they are roomed for at least an hour and are not receiving a consult by social work (SW) for another reason. Three calls are made before concluding contact attempts. During the phone call, families are offered brief counseling, mental health resources, and contact and application information regarding local social resources, such as housing, food, and transportation assistance (Figure). Families who request in-person support, demonstrate significant emotional distress, or identify immediate needs or safety concerns related to potential child abuse, neglect, or intimate partner violence are escalated to an in-person SW encounter. Families receiving multiple resources or requesting follow-up are called by a social worker 1 to 2 weeks after their ED visit.
A growing number of programs nationwide aim to screen and connect families with desired social services.
Recent literature demonstrates low concordance between those who report social risk on screeners and those who desire resources, suggesting that offering social resources either before or in-place of screening may more effectively identify families who desire social assistance.
Considering this, Family Connects was intentionally designed without a screening component. Families are offered support and service referrals, self-determine what is appropriate for their circumstance and the best modality to receive information (ie, text message, email, printed resource). Additionally, the program specifically acknowledges pandemic-related stress and resultant new needs.
At the program's inception, calls were made by social workers and nursing staff with pandemic-related alternative work arrangements. However, system-wide redeployments pulled staffing from Family Connects, creating periods of low outreach. These realities compelled new partnerships with local medical, social work and public health students. This student workforce was trained virtually with asynchronous learning materials and was supported during shifts by ED physician and nursing leadership. This structure allowed for more consistent staffing, while providing meaningful patient interactions and student education on the importance of social determinants of health.
From April 13, 2020, to April 13, 2021, 5355 adult caregivers were called, with 3,882 (73%) caregivers successfully reached. Of those successfully reached, 1,026 (26%) received emotional support, 524 (13%) requested one or more resources, and only 26 (0.7%) were escalated to an in-person social work consult. Frequently provided resources included food (184, 35%), a searchable community resource website (137, 26%), housing (88, 17%), infant and child supplies (82, 16%), utilities (72, 14%), and mental health (59, 11%), with many families (247, 47%) requesting resources in multiple domains.
Quality improvement phone calls were completed with a convenience sample of 8 caregivers after 3 months of program operations to assess acceptability and explore process improvements. Caregivers found the program acceptable, expressed positive feelings towards the program and thought it should continue. Caregivers suggested pre-notification via text message, and more robust follow-up procedures as program innovations. These discussions informed an in-depth qualitative evaluation of Family Connects which will be reported separately, and process improvements detailed below.
Discussion and next steps
Family Connects provides a scalable, interdisciplinary model for delivering holistic care within the ED setting. Through this model, family-level unmet social needs and distress can be addressed in real time. Through a remote infrastructure, Family Connects continues to serve families despite social distancing measures and provides meaningful education for a diverse student population.
Despite the program's success in training students and providing support to many families, there were operational challenges. Family Connects has a high staffing requirement, currently 20 to 25 students with 20 hours each per semester; while this provides family-centered and personalized interactions, programmatic reach is dependent on staffing capacity. The exclusion of screening may result in conversations with families that do not desire resources and suggest the need for opt-out processes. Importantly, while the program has resulted in increased resource referral, we have not yet evaluated engagement with these resources.
Family Connects recently received institutional funding. Texting will be used to initiate contact with caregivers to introduce the program and provide an opt-out mechanism, allowing targeted outreach to families who desire services. All families will receive a link to a local, open-access, community-based organization database via texting, regardless of interest in Family Connects outreach. A dedicated, full time social worker will be hired to enhance follow-up capabilities, and better serve families who prefer resource navigation following their ED visit. Furthermore, we plan to deepen partnerships with community-based organizations most frequently referred to maximize successful resource engagement. Lastly, to continue to support and educate student volunteers, we will formalize a curriculum and offer opportunities for electives and research.
Family Connects represents a new scalable, interdisciplinary, virtual paradigm to provide patient-centered provision of vital resources without screening. Through education and utilization of a student workforce, the ED can continue to expand its role in effectively integrating the social care of families with the medical care of each child.
Disparities in outcomes among COVID-19 patients in a large health care system in California.