Digital Repository Doctoral Projects Spring 2021 Screening Adolescents for Social Determinants of Health in Pediatric Primary Care Emily Daines, RN, MSN, FNP-C Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Daines, E. (2021). Screening Adolescents for Social Determinants of Health in Pediatric Primary Care Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Screening Adolescents for Social Determinants of Health in Pediatric Primary Care by Emily Daines A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 25, 2021 Jessica Bartlett DNP, CNM, RN, IBCLC _____________________________ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE ________________________________ (Graduate Programs Director) . Running head: SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 1 Screening Adolescents for Social Determinants of Health in Pediatric Primary Care Emily Daines, RN, MSN, FNP-C Annie Taylor Dee School of Nursing, Weber State University SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 2 The World Health Organization identifies social determinants of health (SDoH) as the conditions where people live, learn, work, and play and stresses the importance of identifying disparities to improve environments and promote health. The American Academy of Pediatrics advocates for the screening of SDoH in children. Screening at well-child visits allows health care providers to assess social factors influencing patient health. The purpose of this project was to educate providers about SDoH, implement a process to screen adolescent patients at annual well-care visits, and help providers to identify local resources for patients. Provider knowledge was evaluated using a pretest, then education about SDoH was provided. Community resources were collected to be available for patient referral. A process to screen adolescents for SDoH at well checks was implemented for 12 weeks, followed by evaluation. The evaluation was conducted through a post-survey of providers, personal interviews, and chart audits. Once the screening tool was implemented, 88% of patients in the specified group were screened. Of those, 9.4% of patients screened positive for SDoH needs, and 3.6% requested resources. Provider understanding of SDoH improved from 87% to 100%. The success of the project will be demonstrated by the long-term adoption of screening in the clinic. Provider education encourages screening, which can help providers to recognize a patient's need for resources. Ensuring that screening is a permanent part of the clinics protocol will improve patient outcomes. The knowledge gained from this project supports the implementation of SDoH screening in other pediatric practices. Keywords: social determinants of health, screening in primary care, adolescents, social needs, community resources, environment, improved outcomes SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 3 Screening for Social Determinants of Health in Primary Care In recent years, there has been an increasing awareness of social determinants of health (SDoH), the biology of adversity and the profound impact they can have on a person’s well-being (Higginbotham, Crutcher, & Karp 2018). With awareness of their critical impact, there is a growing question of whether screening for SDoH should be performed in primary care clinics (Davidson & McGinn, 2019). This literature review introduces the concept of SDoH and the influence they have on the overall health, development and safety of children and adolescents. The concept of addressing SDoH in the primary care settings to improve outcomes for patients is discussed. Statistically significant evidence is used to support a quality improvement project of evaluating provider knowledge pre and post educational intervention, implementing screening for SDoH in primary care, and providing resources to improve outcomes for adolescent patients. Social Determinants of Health The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, live, work and age and the wider set of forces and systems shaping the conditions of daily life” (WHO, 2020, para.2). Healthy People 2020 has organized SDoH into 5 key domains: 1. Economic stability which includes poverty level and food instability. 2. Education, referring to high school graduate status and early childhood education. 3. Social and community context is explained as concerns about immigration status and social support. 4. Health and health care domains which include health insurance status and access to a health care provider. SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 4 5. Built environment, which refers to neighborhood crime and quality of housing Assessing these SDoH in children and adolescents is particularly important as they are developing skills that will build a foundation for lifelong health and well-being (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [HHS ODPHP], n.d.). Identifying areas of need and intervening early could protect against future health conditions (Sokol et al., 2019). Evidence from around the world suggests that people who are poor and less educated live shorter lives than those with more money and more education (World Health Organization [WHO], 2008). Those who have lower socioeconomic status often live in higher risk environments and encounter more exposure to disease and chronic stress leading to poor health and shorter lives. For example, living in a neighborhood with a higher concentration of convenience stores has been linked to increased tobacco use. Also, having lower availability of fresh produce and a higher concentration of fast-food restaurants has been shown to lend to poor nutrition (Braveman, & Gottlieb, 2014). Other factors such as income and education have been shown, aside from medical care, to influence a person’s health. Medical care accounts for 10-20 percent of modifiable contributors to health outcomes of a population. The remaining 80-90 percent of contributing factors are SDoH (Bradley, Elkins, Herrin, & Elbel, 2011). One SDoH that falls under the Healthy People 2020 category of economic stability is food insecurity. A recent retrospective study by Peltz, and Garg (2019), reports that 15% of US children live in households with inadequate food. Children experiencing food insecurity often have worse physical, emotional, and developmental outcomes. The study found that household food insecurity leads to higher school absenteeism, more emergency department use and lower access to health care. SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 5 Housing insecurity is considered a significant SDoH (Satcher, 2010). The Department of Health and Human Services defines housing insecurity as poor housing quality, unstable neighborhoods, overcrowding, homelessness, or high housing cost in proportion to income (Johnson, & Meckstroth, 1998). Multiple negative health outcomes in children have been linked to poor housing conditions. Some of the negative effects of crowding in the home include altered mental health status, ability to cope with stress, social relationships, and sleep. Poor housing conditions have also been associated with exposure to infectious disease, childhood injuries, respiratory illness, and increased blood pressure (Cutts et.al., 2011). According to a recent WHO guideline, improving housing conditions can prevent disease, increase quality of life, reduce poverty, and save lives. The WHO guideline provides recommendations to reduce health burden due to living conditions and risk factors related to housing (WHO, 2018). Timing of Social Stress Addressing SDoH early reduces negative outcomes. Up to 20% of children experience behavior problems throughout childhood and these are often related to social stressors (Berger- Jenkins et.al, 2019). The connection between psychosocial stress and physical health seems to be compounded by timing, when and for what length of time a stressor occurs makes a difference in the impact on the person. Research has shown that children whose parents have mental health disorders have increased risk of developing a mental health disorder themselves and those with earlier exposure to parental mental health disorders are at greater risk of impact on their mental health. For example, maternal depression exposure during infancy vs toddlerhood has a stronger influence on a child’s internalizing disorders. Adolescence is another period of heightened sensitivity to parental stressors (Hu, Taylor, Glauert, & Li, 2019). SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 6 The COVID-19 pandemic and increased unemployment rates across the country have increased the potential for increased SDoH (Paramour, Nandi, Serag, & Baum, 2021). Screening for SDoH will likely become a higher priority for all healthcare providers as they assist patients in navigating new social stressors related to the pandemic. The timing of this project has been beneficial in helping the providers at Busy Bee Pediatrics to implement screening as patient’s social needs are increasing. Screening for SDoH With the growing understanding that SDoH influence the physical and mental health of people and the knowledge that childhood is a time in which there may be increased vulnerability to poor social circumstances, pediatric primary care clinics are an ideal setting to conduct screening. The practice of screening for these determinants is becoming a standard recommendation from professional organizations. The American Academy of Pediatrics (AAP) recommends that some type of screening, verbal or electronic, be conducted during all patient encounters (American Academy of Pediatrics, 2020). Screening for SDoH allows health care providers to assess social factors that are influencing a patient’s health and offer referral to resources (Andermann, 2018). Despite the practice of screening becoming an expectation in primary care settings, there is not a standard or recommended method or tool and many providers have not yet embraced this practice. For health care workers to improve patient access to resources, they must first be aware of the patients existing social risk factors. Screening patients through improved social history taking or a formal screening tool in clinical practice is a growing recommendation (Andermann, 2018). One study looked at various tools being utilized and found that there are many different options available to screen adults, some addressing a single social factor and others are more SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 7 comprehensive (O’Brien, 2019). According to Andermann (2018), relatively few screening tools have been identified to screen for SDoH in pediatrics. Sokol, et. al. (2019) conducted a comprehensive review of available SDoH screening tools, their efficacy in detecting indicators for risk, and whether they are shown to inform care. Evidence is lacking on which SDoH have the most impact on child health and therefore pediatricians are encouraged to tailor SDoH screening to specific patient needs and available resources in the community (Sokol, et. al., 2019). Project Plan Busy Bee Pediatrics is a primary care pediatric clinic and a patient centered medical home (PCMH). Prior to this project, SDoH screening had been conducted for young patients using the SEEK tool for several years, but no screening had been implemented for adolescents. As a PCMH, the clinic is continually setting goals for quality improvement. A gap was identified regarding screening for SDoH in the adolescent age group. A project was planned involving assessment of provider understanding of SDoH with a pre-project questionnaire followed by an educational module. At the completion of the project, providers would participate in a post-project questionnaire. Another aspect of the project was to be a focused evaluation of the best practice for implementing SDoH screening for adolescents in the clinic. Screening was to be implemented and integrated into clinic flow. A thorough search and review of local resources related to SDoH would also be conducted. Resources would be compiled and organized so they would be available to distribute to patients who identified social needs. As patients screened positive for SDoH and requested resources, local resources would be provided through the patient portal. Expected Outcomes SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 8 The purpose of this quality improvement project was to increase provider awareness of SDoH, implement a process for screening, collect resources for patient referral, and ultimately to improve patient outcomes. Outcome one of this project was to improve provider knowledge of SDoH and of the screening tool. Assessment of provider understanding was measured by a custom-made pre-test followed by an educational intervention and finally a post-test. The topic of SDoH has not yet been systematically taught in nursing and medical schools. For health care providers to contribute to health promotion and disease prevention, it is essential that curriculum be developed to better prepare health care professionals with an understanding of SDoH for future practice (Baverstock, Gargya, Jackson, & Stupans, 2018). Despite clear evidence supporting the impact of SDoH on child health, it has not been universally accepted as a routine part of well-childcare (Higginbotham, Crutcher, & Karp, 2019). Because of the lack of prior education surrounding this topic, this project provided a brief comprehensive overview of SDoH and the benefit of screening patients to the providers in the clinic. Outcome two was implementation of a routine process for screening for SDoH that would become standard of care for patients age 11-18 during annual well-checks at Busy Bee Pediatrics. This was measured by monthly reports collected from the electronic health record (EHR). The AAP Policy on Health Equity (2010) highlights primary care appointments as an appropriate setting to screen for social needs of patients. Evidence shows that identifying the burden of unmet needs related to SDoH is the first step to connecting people to resources available in their communities to address those needs and improve their health (Billioux, Verlander, Anthony, & Alley, 2017). By establishing a system for screening of patients for SDoH at well care visits, providers were able to collect information needed to offer appropriate SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 9 assistance. Patients generally trust their primary care providers and accept their suggestions and resources, so primary care is an ideal setting to implement such a process. Outcome three was identification of needs and distribution of appropriate resources to patients who requested them. Distribution of resources was measured by a review of the EHR to account for the total and specific resources that were provided to patients. A randomized trial conducted in Boston, Massachusetts showed that screening for SDoH such as child-care, food insecurity, household heat, housing, parent education and employment, led to increased provider referrals to support services. The study also identified a reduction in the use of homeless shelters at one year follow up compared to previous standard clinical care (Andermann, 2016). Connecting patients with resources within and beyond the healthcare system can decrease negative outcomes including suicide attempts, alcoholism, and use of street drugs (Van Neil, Pachter, Wade, Ferletti, & Stein, 2014). Setting and Population This project was conducted at Busy Bee Pediatrics, a primary care pediatric clinic located in Bountiful, Utah. This clinic serves Bountiful and other surrounding cities in Davis County. Davis county has a population of roughly 300,000 with one third of the population being 18 years or younger. Most of the population, 170,000, is white followed by Hispanic at 16,000, Asian 4,500 and Black 2,500. The median income is $80,000 (World Population Review, 2020). Busy Bee Pediatrics serves as a medical home for 4,700 patients age 0-19. Of the patients seen in the clinic, 1,650 are age 11-18. Approximately 100 well-checks are completed monthly for this age group by all providers in the clinic. The providers in the practice include one pediatrician, four pediatric nurse practitioners and two family nurse practitioners (M. Hatch, personal communication, March 16, 2020). SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 10 Busy Bee Pediatrics became a NCQA recognized Patient-Centered Medical Home (PCMH) in 2018. A PCMH is committed to providing quality experiences for patients while reducing cost and focusing on continuous quality improvement and patient-centered care (PCMH, n.d.). Busy Bee Pediatrics considers the social circumstances of each patient to be relevant in the overall health of children and an important aspect of patient-centered care. The providers at this clinic have acknowledged screening for social determinants of health (SDoH) as a method for identifying social circumstances of patients. According to the AAP (2019), fewer than 50% of pediatricians report that they usually or almost always screen low-income parents for social needs. Many barriers to screening in a primary care setting have been identified including but are not limited to: determining the proper method for screening, time involved to conduct screening, time to address needs that are discovered, a feeling of being unprepared to address needs identified, low availability of resources to address needs, concern that patients will be uncomfortable answering questions, and the idea that social workers would be better equipped to conduct the screening (Davidson, & McGinn, 2019). Other considerations include logistical challenges, staff roles, and integration into the electronic medical record (Byhoff, et.al., 2019). Some of the anticipated barriers to screening in this specific population are; providers not buying into a change in process and an added demand on their time, patients not endorsing a need for resources considering the dominant religion and resources available to them, and patients being unwilling to disclose needs for fear of discrimination. Busy Bee Pediatrics has been screening for SDoH in young patients for several years. They are using a screening tool called Safe Environment for Every Kid (SEEK). Prior to this project, there was not a standard process at the clinic for screening adolescents. This project SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 11 included educating providers about SDoH, careful selection of a screening tool, development of a process for screening adolescents ages 11-18 at well child visits, implementation of screening, accumulation of resources available and creating a method to deliver resources to patients. Evidence-Based Practice Model ACE Star Model The ACE Star Model is a framework that was developed to organize evidence-based practices and systematically put them into operation. This model is configured as a simple 5- point star depicting the major stages of knowledge transformation including, discovery, evidence summary, translation, implementation, and evaluation (Stevens, 2002). This model has provided a framework for the project that has been easy to follow. Each point and their use in the project is explained below. “Discovery” was utilized in conducting a thorough literature review regarding screening for SDoH in primary care settings. Various research designs such as randomized controlled trials, case control studies and qualitative studies were examined during this process. “Evidence Summary” involved collecting information which was summarized into the following statement. Social Determinants of Health (SDOH) including income level, education, social status, and social support are correlated with poor patient outcomes and increased morbidity. Many organizations are recommending screening for SDOH in the primary care settings. In the ACE Star Model, the “Translation” step suggests providing a summary of the evidence in a form that can be easily utilized. Translation occurred through the creation of a care process model that fits into the setting and flow of the clinic. “Implementation” occurred with a twelve-week pilot project in which the process was being tested. Eleven to eighteen-year-old patients seen in the clinic for well-child visits during the pilot period were given the screening tool prior to arrival. SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 12 The screening was reviewed by the provider and discussed with the patient and parent during the visit. If a need was identified, the provider followed a planned process for referring resources to the family. “Evaluation” was conducted by a survey of providers and conversations with other clinic staff. Review of reports from the electronic medical record provided an overview of screening results and identified which resources were being requested and distributed. Project Implementation Implementation Procedure For the protection of human subjects, a project proposal was submitted for Institutional Review Board (IRB) approval. This project involves minimal risks to participants and patient participation was voluntary and was determined to be exempt by the IRB at Weber State University (See Appendix A). Possible ethical considerations included hesitancy of patients to complete screening for fear of discrimination, avoidance of any HIPAA violation and assurance that parent consent had been obtained prior to screening minor patients. For each patient, a parent consent is signed to receive treatment at the clinic and therefore the screening was authorized as part of care in the clinic. Participation in the screening was voluntary. This project had excellent administrative support as it was consistent with a goal previously identified by the medical director in meeting needs of the clinics PCMH accreditation (B. Feola, personal communication, November 2, 2019). Approval was granted from Dr. Bonnie Feola, medical director at Busy Bee Pediatrics (See Appendix B). The costs involved in conducting this project were minimal. Training providers and other office staff on the process of conducting the screening was a cost that the clinic absorbed. There was a small cost associated with time required to collect and compile resources for distribution to patients. Some of the barriers that were identified were patients not completing the screening prior to arriving, SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 13 confusion of some patients about the questions asked, providers failing to address the screening with patients, and patient or parent discomfort in discussing sensitive topics. Prior to implementation of the screening in the clinic, seven providers including one pediatrician, four pediatric, and two family nurse practitioners were given a survey addressing their knowledge of SDoH. The survey was distributed through Survey Monkey, responses were anonymous (See Appendix C). Following completion of the survey, providers received an educational video on SDoH. Due to the COVID-19 pandemic, in-person meetings were not possible. The presentation included: 1. Explanation of SDoH and how they impact pediatric patients. 2. Evidence supporting screening in primary care. 3. Review of the resources available for specific SDoH and a list of what would be distributed to patients. 4. Project implementation procedure. Added training on a one-on-one basis occurred throughout the pilot period as needed. After a thorough review of available screening tools and evaluation of evidence relating to each, two options were considered. A simplified version of the PRAPARE tool or the Health Screening – SDoH were the two options. The decision was made, with Dr Feola, to use the Health Screening-SDoH (See appendix D). This tool is a concise eleven-question survey that evaluates food, housing/utilities, transportation, interpersonal safety, and a patient’s desire for assistance. The Health Screening-SDoH was available for use through CHADIS (Comprehensive Health and Decision Information System), a system used by the clinic to distribute all screening tools electronically to patients. Because it was available in CHADIS and ready to use, the screening tool was able to be assigned immediately to patients at the implementation of the SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 14 project. Patients in the practice are familiar with the CHADIS screening process so there was very little patient education needed regarding the process for completing the screening tool. Screening was conducted over a period of twelve weeks. Every four weeks, the Doctor of Nursing practice (DNP) student utilized the electronic medical record to compile a list of patients ages 11-18 scheduled for well-checks for the following week. Using the list of patients, screening tools were sent to patients 5-7 days before their visit via the CHADIS system. If the screening tool had not been completed 1-2 days prior to the visit, a reminder message requesting completion was sent to the parent through the patient portal. Medical assistants (MA) and office staff were trained on the process for screening and the change in their workflow. MAs checked for completed screening when the patient arrived and if it wasn’t finished, they assisted the patient using the clinic’s tablet to complete the screening through CHADIS prior to the provider entering the room. Once screening was completed, the MA selected the button in the chart to alert the provider it had been ordered, he or she then attached the completed screening to the day’s visit in the electronic chart. The provider briefly reviewed the screening tool with the patient. If the patient had indicated on the tool that they desired resources, the provider created a task requesting that the patient receive resources. During the project, the DNP student responded to these tasks by sending resources to parents via the portal. At the completion of the project, the DNP student trained the nurse care coordinator to provide resources to patients. Each month during the pilot period, data was collected and evaluated by the DNP student. Evaluation and Data Analysis Data Collection Data was collected through surveys assessing provider knowledge about SDoH. Pre and post surveys were developed to address understanding and awareness of SDoH and provider SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 15 support of screening in this setting. The surveys included a 5-point Likert scale with answers ranging from strongly disagree to strongly agree to determine providers baseline knowledge of SDoH. Percentage of providers completing training and surveys was tracked. Pre and post survey scores were evaluated to determine if providers understanding increased with the educational intervention. The total number of screening forms distributed to patients, the percentage of patients screening positive, and those requesting resources was evaluated by chart audit over the 12-week pilot period. The number of screening tools completed was reviewed and tallied monthly via reports run from the EHR to determine compliance of providers and success of the distribution process. The results were evaluated using tables and figures and descriptive statistics. Results The clinic was not previously screening for SDoH in patients aged 11-18 years, so any increase in provider screening was beneficial. Over the 12-week pilot period, 139 patients in the specified age group were seen for well checks, 123 (88.5%) completed the screening tool. Of those who were screened, thirteen (9.4%) patients screened positive for one or more social determinants and five (3.6%) patients requested resources for those needs (See Appendix E). As anticipated, following an educational module, provider knowledge about SDoH increased. All seven of the providers, one MD and 6 NP’s completed both screenings. Nearly all providers indicated that screening for SDoH in primary care is important and all indicated they have an in-depth understanding of SDoH and are comfortable addressing the screening with their patients. There was no change from pre to post survey in provider belief that screening for SDoH in the primary care setting is important (See Appendix F). At the end of the survey, providers were supportive of ongoing screening and contributed the following comments. SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 16 “Continue teaching providers the importance that SDoH have on our ability to care for our patients appropriately.” “Very important for treating the whole patient with a patient centered approach.” “Hopefully, it will ultimately improve outcomes.” “Very important for overall health and especially future outcomes!” “SDoH is such an important part of heath care that needs to be recognized! And will only become more relevant with the COVID crisis!” “I feel that it is an important issue that affect the health and well-being of our patients and their families. I believe insurance companies could take a larger part in paying for this added service as it improves outcomes.” “I believe access to exercise and ability to exercise should be included as a SDoH” Discussion The project at Busy Bee Pediatrics was successful in educating nurse practitioners and other providers on current evidence regarding SDoH in pediatrics. The project was successful at creating and implementing a screening process which met a clinic goal and assists in maintaining PCMH status. The knowledge that was gained by providers during this project will be most valuable to patients if it leads to continued screening for SDoH followed by addressing patient needs through ongoing evaluation and providing community resources. An additional strength was the timeliness of the project. Prior to the global pandemic, SDoH and the need to address them had been gaining attention in medical communities. Now there are many more social instabilities caused by the pandemic. Many families have reported concerns about financial stability, employment, food availability, housing stability, and health SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 17 care access as a result of the impact of the COVID-19 pandemic (Sharma, Chuang, Rushing, Naylor, Ranjit, Pomeroy & Markham, 2020). Limitations. One limitation to the project was the demographic of the patient population served by the clinic. The clinic is in an affluent and highly religious area of a suburban community. Many patients of the clinic have robust family support systems and support from their religious communities when needed. In an area with higher socioeconomic need, this type of screening would be of increased value. A second limitation is the wording of this specific screening tool, Health Screening - SDoH. Some patients misunderstood the questions and answered yes to questions that should have been answered differently due to confusion when reading the screening tool. A thorough explanation was provided at the top of the tool but there seemed to be a percentage of patients who misunderstood or did not read the explanation. Sustainability and recommendations. Increasing attention from the AAP, CDC and other national organizations on the impact of SDoH on overall health, supports ongoing use of the process that was established during this project. Staff members and providers at Busy Bee Pediatrics were trained, the process is in place and running smoothly, and patients are becoming familiar with the screening. Resources have been compiled and are easily accessed to provide to referrals as needed. All these things contribute to sustainability of ongoing screening of adolescents in primary care. As the clinic moves forward with the screening, the care coordinator should establish a process for ongoing collection of updated local resources as they will change over time. A recommended change in the current process is to provide a clearer explanation, to patients and parents, of the purpose for screening. Screening for SDoH is becoming more common in SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 18 healthcare and exposure to screening in other healthcare settings will help to increase familiarity for patients and families. Conclusion A strong association exists between SDoH such as decreased income, education, social status and social support during childhood and adult health outcomes (Song, Hall, Harrison, Sharpe, Lin, & Dean, 2011). Despite some gaps in the evidence regarding specific methods for screening, pediatric providers have a pivotal role in identifying patients with social needs (Higginbotham, Crutcher, & Karp, 2018). 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Social determinants of health. Retrieved from: https://www.who.int/social_determinants/en/ Pediatrics, 144(4) e20191622. doi:10.1542/peds.2019-1622 SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 23 World Health Organization. (2018). WHO housing and health guidelines. Retrieved from https://www.who.int/sustainable-development/publications/housing-health-guidelines/en/ World Population Review (2020). https://suburbanstats.org/population/utah/how-many-people-live- in-davis-county. Accessed 22 Feb 2020 SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 24 Appendix A SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 25 Appendix B SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 26 Appendix C Survey Questions Provider Social Determinants of Health Assessment Please select the answer that best represents how you feel. 1 = Strongly agree 2 = Agree 3 = Neither agree nor disagree 4 = Disagree 5 = Strongly disagree 1. I have an in-depth understanding of Social Determinants of Health (SDoH) and the affect they have on my patients. 2. I believe it is important to address SDoH in the pediatric primary care setting. 3. I have received training and/or education on SDoH. 4. I am comfortable addressing SDoH with my patients and/or parents. 5. I am aware of and comfortable with the current process at Busy Bee Pediatrics for providing community resources to patients who indicate a need. SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 27 Appendix D Health Screening - SDoH We believe everyone should have the opportunity for health. Some things like not having enough food or reliable transportation or a safe place to live can make it hard to be healthy. Please answer the following questions to help us better understand you and your current situation. We may not be able to find resources for all of your needs, but we will try and help as much as we can. Food 1. Yes No 1. Within the past 12 months, did you worry that your food would run out before you got money to buy more? 2. Within the past 12 months, did the food you bought just not last and you didn’t have money to get more? Housing/ Utilities 2. Yes No 3. Within the past 12 months, have you ever stayed: outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else’s home (i.e. couch-surfing)? 4. Are you worried about losing your housing? 5. Within the past 12 months, have you been unable to get utilities (heat, electricity) when it was really needed? Transportation SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 28 3. Yes No 6. Within the past 12 months, has a lack of transportation kept you from medical appointments or from doing things needed for daily living? Interpersonal Safety 4. Yes No 7. Do you feel physically or emotionally unsafe where you currently live? 8. Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by anyone? 9. Within the past 12 months, have you been humiliated or emotionally abused by anyone? Optional: Immediate Need Yes No Do not care to answer 10. Are any of your needs urgent? For example, you don’t have food for tonight, you don’t have a place to sleep tonight, you are afraid you will get hurt if you go home today. 11. Would you like help with any of the needs that you have identified? SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 29 Appendix E 139 100.0 123 88.5 13 9.4 5 3.6 0 20 40 60 80 100 120 140 160 Number of patients Percentage Number of patients Percentage Requesting Resources 5 3.6 Positive Screening 13 9.4 Patients Screened 123 88.5 Total number of patients 139 100.0 Results of SDoH Screening SCREENING FOR SOCIAL DETERMINANTS OF HEALTH 30 Appendix F 0% 20% 40% 60% 80% 100% 120% I have an in-depth understanding of Social Determinants of Health (SDoH) and the effect they have on my patients. I believe it is important to address SDoH in the pediatric primary care setting. I have received training and/or education on SDoH. I am comfortable addressing SDoH with my patients and/or parents. I am aware of and comfortable with the current process at Busy Bee Pediatrics for providing community resources to patients who indicate a need. Healthcare Provider Knowledge on SDoH - pre and post test results - N=7 Post-test Scores Pre-test scores