Pediatric Population Health: Support Families with Health-Related Social Needs
“Hi. My name is Ronnie, a care manager with ABC Pediatrics, and I’m calling to check on your daughter Jenna. I see that she missed her last well-child visit, and I wanted to find out if there is anything I can do to help you reschedule the appointment or ensure you have transportation for the next visit.”
To many people, this may sound like an example of helpful outreach. But to families with insufficient financial and support resources, this can be a really stressful and potentially embarrassing interaction that could require taking a day off from work, coordinating transportation, and managing unexpected costs.
Despite their best efforts and intentions, care managers sometimes encounter challenges engaging parents and caregivers in care management services. Some of the most common reasons families are hesitant to engage include:
Lack of trust: Many of the families that are most in need of assistance have had negative experiences with health care and government systems. It’s only natural that they are reluctant to engage with another organization claiming to have their best interests in mind.
Vulnerability: This goes hand-in-hand with lack of trust. It is stressful to deal with a care manager looking for information that can be embarrassing to admit. Parents and caregivers may also be fearful about the consequences of a response they feel could potentially impact their family’s well-being or financial security.
Internal family challenges: Many families may face additional 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 healthcare.
To overcome these challenges, care managers must build a strong foundation of trust. This doesn’t happen overnight but rather over time, through empathy, active listening, and helping the family meet immediate needs, such as food security, stable housing, financial assistance, or child care.
The Importance of Social Determinants of Health
Children are reliant on adults for their basic needs. Therefore, it’s especially important for the child’s care team to gather as much information as possible about each family’s social determinants of health (SDoH) and health-related social needs, and work to bridge any gaps by connecting them to the appropriate resources.
In North Carolina, for example, the Department of Health and Human Services (DHHS) recognizes these four unmet health-related resource needs domains as a priority for the Medicaid population: food insecurity, housing instability, lack of transportation, and interpersonal violence. They have developed a standardized set of SDoH screening questions around these four needs. By standardizing screening questions and having a consistent screening approach, providers, payers, and care management organizations can identify needs and provide interventions and immediate linkage to services, resources, and supports. It also allows for the collection of data on unmet health-related needs of populations and the ability to assess the impact on health outcomes and overall cost.
Social issues like these, especially when encountered regularly, can negatively impact the health outcomes of children from any background. That’s why it’s essential to build trust and ask questions in all child health care settings – whether it be primary, specialty, or through other care team outreach.
Connected Care Management Can Improve the Health of Children at the Highest Risk
Connected care helps identify and address SDoH and serve the entire family’s social needs (e.g., food access, transportation, etc.) while connecting the dots across school, the clinical setting, and family life. When it comes to children, whole-person care requires not only family engagement and the collection of information, but also the connectivity to share that information across the care team.
Breaking down the barriers to patient engagement requires collaboration across sectors, from pediatric health care services and the education system to community organizations designed to improve family life and other support services. A care manager, and the entire care team, should have access to data from services and resources across physical and behavioral health, early care and education, schools, housing, transportation, food, public health services, child welfare, mobile crisis response, community health services, juvenile justice, legal aid, and more.
That way, if a school counselor discovers that a child's 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 to further assess the needs and help connect the child and family to the appropriate services, resources and supports, such as helping complete a Supplemental Nutrition Assistance Program (SNAP) application or setting up transportation to medical appointments. Integrated data with shared information and access also allows anyone on the care team to see the full picture of what a family needs and help ensure those needs are met.
Healthcare organizations need to leverage a connected care system to not only ensure that information is shared among all providers and care team members, but also to track family engagement rates and outcomes. By analyzing which care managers have the highest engagement rates, they can then get details about their success and share those best practices with other care managers. This ultimately supports the goal of advancing a care model that works across communities and is sustainable in the long term.