305 - Referrals for Social Determinants of Health Screening

Poster Number: 305
Publication Number: 305.2218

Background: Social determinants of health (SDOH) are non-medical factors that impact a child’s health and well-being. At our institution, patients who screen positive for SDOH needs are referred to a team of community health workers, case managers, and social workers, which is called the CARE team.

Objective: This retrospective study was created to analyze the interactions and resources provided to pediatric patients by the CARE team.

Design/Methods: The population is a subgroup of a larger study of pediatric patients with a well-child visit at a university-based pediatric primary care clinic from 08/22/22 through 12/30/22. Patients included in this study screened positive in one or more SDOH domains on the 12-item SDOH questionnaire and were referred to the CARE team. A retrospective chart review was conducted. All data was stored in Redcap and analyzed with descriptive statistics.

Results: There were 2,205 patients with well-child visits included in the original study, and 259 met inclusion for the subgroup of this study. Of the 259 patients with one or more social need, the most common needs that screened positive were financial resource strain (40.9%), housing instability (36.3%), and food insecurity (31.7%).

Of the 259 patients, 88% had a CARE team member reach out to the family. Community health workers reached out in 50.4% of cases, along with social workers (25.4%), and case managers (24.1%). Of the 228 patients who had a CARE team member reach out, they made contact with 81.6% of the patients or families, and 87.3% were provided resources by the CARE team. Contact ranged from one encounter (57.5%), two (24.1%), three (9.2%), four (6.1%), and up to five or more encounters (3.1%). In the cases of a CARE team member not making contact with the family, resources were still provided to 66.7% by mail. Families commonly received an aid packet (67.3%) as well as information for specific community resources including housing/ rent assistance (43.7%), SNAP/WIC (37.7%), utility assistance application (35.7%), our institution's medical legal partnership (33.7%), meal delivery (30.7%), insurance (27.1%), and Food Banks (26.6%).

Conclusion(s): The majority of patients who were referred to the CARE team for needs related to SDOH were contacted by the CARE team and received resources. The results of this study provide additional information regarding the nature of the CARE team interactions and community resources provided. This information can help guide future interventions by medical providers and healthcare systems as they work to expand SDOH screening.