Pediatric Populations: How Can Care Managers Engage Families with SDOH-Related Needs?

A national survey of parents with children under the age of 18 found that:

  • 32% missed at least one pediatric medical appointment in the last year because they were unable to get to it or pay for it.
  • 30% reported not having enough time to focus on their child’s health unless it’s a medical emergency.
  • 23% were experiencing food insecurity. 

Despite their best efforts and intentions, care managers sometimes encounter barriers when trying to engage families of pediatric members facing these and other social determinants of health (SDOH)

How SDOH Needs Impact Family Engagement and Outcomes

As the study referenced above found, many families of pediatric members face challenges such as transportation, housing or food insecurity, behavioral health conditions, substance use, or interpersonal safety concerns. These can be barriers to fully engaging in their children’s health care.

Consider a family with insufficient financial or support resources getting a call from their care manager to re-schedule a missed pediatric appointment. This well-intended outreach could be a stressful event that requires taking a day off from work, coordinating transportation, and managing unexpected costs.

Some common reasons families are hesitant to engage include:

  • Lack of trust: Many families that are most in need of assistance have had negative experiences with healthcare and government systems. As a result, they may be reluctant to engage with another organization claiming to have their best interests in mind.
  • Vulnerability: This goes hand-in-hand with trust. A care manager asking for potentially embarrassing information can be very stressful. Parents and caregivers may also be fearful of the consequences of a response that could impact their family’s well-being or financial security.

Meanwhile, a study published in the Journal of Pediatrics found that families experiencing a social need were less likely to engage in preventive care, but more likely to experience an in-patient or ED visit for their children. 

Connected Care Management Can Improve Children’s Health

Connected care helps to identify and address SDOH and serve the entire family’s social needs (e.g., food access, transportation, etc.). To successfully deliver connected care for pediatric populations, the care management team needs to see the big picture across school, the clinical setting, and family life.

Here are some ways to achieve that visibility and support care management that builds engagement among families of pediatric members.

Standardize Information Gathering

Use consistent methods to gather as much information as possible about each family’s SDOHs and health-related social needs. With standardized screening questions and a consistent screening approach, providers, payers, and care management teams can identify needs and provide interventions and immediate links to services, resources, and supports. 

This also allows for the collection of data on unmet health-related needs, supporting the assessment of the impact on health outcomes and overall cost. In North Carolina, for example, the Department of Health and Human Services (DHHS) has developed a standardized set of SDOH screening questions around food insecurity, housing instability, lack of transportation, and interpersonal violence. 

Earn Trust and Deliver on Meeting Needs

To overcome barriers like distrust and feelings of vulnerability, care managers must build a strong foundation of trust. This doesn’t happen overnight but rather over time, through empathy and active listening.

Taking immediate and direct action by connecting families to services when they confide their needs is critical to maintaining trust. This means linking them to available resources such as food pantries or nutrition programs, housing assistance, transportation services, financial assistance, or child care.

Learn how VirtualHealth helps healthcare organizations bridge gaps for members with SDOH-related needs. Download the white paper here.

Centralize Data to Strengthen Collaboration & Follow-Up Coordination

For true collaboration that can break down engagement barriers, the entire care team should have access to data from sectors and resources such as:

  • Physical and behavioral health
  • Early care and education
  • Schools
  • Housing and transportation
  • Nutrition support
  • Public health services
  • Child welfare
  • Mobile crisis response
  • Community health services and organizations
  • Juvenile justice and legal aid

Integrated data with shared access fosters collaboration, so anyone on the care team can see the full picture of what a family needs and help ensure those needs are met.

For example, if a school counselor discovers that a family is facing food insecurity, or a provider’s office identifies that a child is consistently missing routine visits, the care manager can follow up for further assessment. They can then take steps to connect the family to appropriate services, resources, and supports (e.g., applying to the Supplemental Nutrition Assistance Program or setting up transportation to medical appointments). 

Learn how HELIOS integrates member data for tighter coordination of care

Track Family Engagement and Outcomes

By analyzing the care managers who have the highest engagement rates, leadership can share best practices with other care managers and improve the entire organization. This will promote a care model that works across communities and is sustainable in the long term.

Want more on connected care management? Learn how HELIOS supports population health to strengthen member engagement.

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