Overview

This project with the Pediatric Physicians’ Organization at Children’s (PPOC) utilized a social  health needs assessment screening tool to improve primary care providers’ capacity to address the social determinants of health.

Organization Name

Pediatric Physicians’ Organization at Boston Children’s Hospital

Organization Type

• Physician's organization

National/Policy Context

• Socioeconomic status, particularly among children, has been consistently shown to be associated with health outcome measures including physical health, social health, and educational achievement.
• Social screens are recommended by the Academy of Pediatrics as useful tools to detect social needs of children in the primary care setting.

Local/Organizational Context

• While many of the various social screening tools lack validation, these tools may still be beneficial in clinical practice. The authors recognized that they could adapt and implement the Health Leads Recommended Screening Tool to effectively screen their pediatric population for social needs.
• The Pediatric Physicians’ Organization at Children’s (PPOC) is made up of more than 500 physicians, nurse practitioners and physician assistants devoted exclusively to pediatric primary care, in close collaboration with subspecialists at Boston Children’s Hospital.

Patient Population Served and Payor Information

• Patients targeted by this program were children and their families who had either commercial insurance or Medicaid ACO insurance.

Research + Planning

• The Health Needs Assessment (HNA) and Toolkit were designed for use by PCPs at Boston Children’s Hospital.
• The HNA was translated into 6 languages.
• Physicians were trained to administer and document results of HNA during patients’ well visits.

Tools or Products Developed

• Health Needs Assessment (HNA) & Toolkit: An adapted version of the Health Leads screening tool to be used by the Boston Children’s Hospital PCPs and was embedded into the EHR.  
  • The HNA measured categories of patient needs including: financing utilities, outside support, hazards in home, hunger, stable housing, understanding health needs, transportation concerns, missing school or work, safety at home, and financing health needs.

Training

• PCPs were trained on the HNA using in-person meetings, webinars, tipsheets, and a toolkit.
  

Tech Involved

• Electronic medical record
• Statistical software
• Virtual meeting platform

Team Members Involved

• Administrative Assistant
• Care Coordinator
• NPs
• PAs
• Physicians

Workflow Steps

• PCPs distributed the HNA to patients and their families both on paper and verbally, and then documented the results in the EHR.

Budget Details

• Costs associated with developing HNA and Toolkit
• Costs associated with development of training and resource materials 
• Labor costs associated with trainings of physicians and staff members
• Integration costs associated with integrating the HNA into the EHR

Where We Are

• Date (Month/Year) Project Described Started: June 2018 – December 2018
• Date (Month/Year) Paper Published: April 2019

Outcomes

• Patients Screened: Total number of patients who were screened from June – December 2018
  • 47,137 total patients screened (12% of total network)
    • 66% of commercially Insured patients were screened (31,309)
    • 34% of Medicaid ACO Insured patients were screened (15,828)
• Social Need Identified: Total number of patients who had a social need identified by the HNA screen
  • 3,193 patients identified a social need (7%)
    • 3% of screened Commercially Insured patients identified social need
    • 14% of screened Medicaid ACO Insured patients identified social need
  • Financing utilities (2.8%), outside support (2.8%), hazards in home (2.7%) were the top categories of need.

Future Outcomes

• Future outcome analyses include:
  • Completion of care plans after identifying social needs
  • Barriers to addressing social needs
  • Understanding family/patient decisions in declining PCP assistance after addressing needs

Benefits

• The HNA guides PCPs to utilize the opportune setting of an annual well visit to continually assess social needs of children and their families, allowing the space for intervention and help if needed.
• Earlier interventions can help relieve children from negative social determinants of health.

Sources

• Bittner, J., Pelletier, N., Trudell, E., Hatoun, J., Donahue, S., Vernacchio, L. (2019, April). Identifying Social Needs in Pediatric Primary Care: Implementation of a Health Needs Assessment. Poster session at the Institute for Healthcare Improvement Summit on Improving Patient Care, San Francisco.