Referral and Resource Utilization Among Food Insecure Families Identified in a Pediatric Medical Setting

Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study

BACKGROUND AND OBJECTIVES

With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness.

METHODS

We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test.

RESULTS

In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001).

CONCLUSIONS

This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.

Comparison of Caregiver and Provider Food Insecurity Screening Preferences Within a Health System

Food insecurity is a public health concern associated with poor health. Evidence guiding how to best implement screening for food insecurity across a pediatric health care system is lacking. We performed a single-center, multi-department, cross-sectional study of caregivers and health care providers in outpatient and inpatient settings to describe the beliefs, barriers, preferences, and preferred food insecurity screening location. Most providers and caregivers underestimated the pervasiveness of food insecurity while acknowledging the benefit of screening. Caregivers are overall receptive to food insecurity screening and disagree with feelings of discomfort or shame when disclosing food insecurity status. Providers acknowledged perceived caregiver discomfort, lack of community food resources, and lack of a validated screening tool as barriers to screening. Both caregivers and providers identified the primary care setting as the preferred screening setting.

Health-Related Social Risks Versus Needs in a Pediatric Emergency Department

INTRODUCTION

Health-related social problems may be conceptualized as the presence of either a social risk (i.e., food insecurity as defined by a screening tool) or a social need (i.e., desire for referral to a food program). Identification of social risks may not correlate with patients' desire to receive help. This study aimed to identify and compare patients and families with social risks versus social needs in a pediatric emergency department.

METHODS

This was a planned secondary analysis conducted in 2023 of a previously published prospective intervention study, which screened and referred caregivers and adult patients for health-related social problems in an urban tertiary pediatric emergency department between May 2019 and October 2020. Participants completed a screening tool for social risks and self-identified social needs by selecting desired assistance from a list of social service categories. Participants' social risk screening results were compared with their selection of resources for social needs across demographic and socioeconomic characteristics and the number of positive social risks using chi-squared or Fisher's exact tests.

RESULTS

Of 258 participants, 42.2% (109) screened positive for any social risk, and 38.0% (98) self-selected a social need. Of those, only 59.2% (77/130) both screened positive and self-selected a need. Among those who screened positive for a social risk, several demographic and socioeconomic factors including race, ethnicity, and income were significantly different between those interested versus not interested in assistance.

CONCLUSIONS

Both social risks and self-identified social needs should be considered within social care interventions in the pediatric healthcare setting.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic

INTRODUCTION

This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care.

METHODS

This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit.

RESULTS

Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96).

CONCLUSIONS

There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

Improving food insecurity screening across a health system throughout the COVID-19 pandemic

BACKGROUND

Food insecurity has direct and indirect negative outcomes on the physical and mental health of children, with impacts throughout adult life. Rates of food insecurity have increased dramatically since the start of the COVID-19 pandemic. The American Academy of Pediatrics recommends paediatricians screen and intervene to address food insecurity. We aimed to increase the percentage of patient encounters with food insecurity screening completion at the paediatric medical home from 0% to 85% by July 2020 with extension to the paediatric emergency department (ED) and paediatric specialty clinic in the following year.

METHODS

This multicentre project occurred in three sites within our health system: a teaching safety-net, paediatric medical home; a paediatric ED; and five divisions within paediatric specialty medical clinics. A screening tool was created using the validated Hunger Vital Sign Questionnaire. A standard screening, documentation and referral process was developed. The Model for Improvement was used testing changes via Plan-Do-Study-Act cycles.

RESULTS

The percentage of households screened for food insecurity increased from a median of 0% to 30% for all sites combined. There was significant variability in screening with the ED screening a median of 24% and the medical home screening 80% by the end of the study period. A total of 9842 households (20.9%) screened were food insecure. During the study period, 895 families with 3925 household members received 69 791 pounds of food from our primary community resource using our clinic's food prescription. Of these families, 44% (398) also qualified for the US Department of Agriculture programme ensuring ongoing food distribution up to twice a month.

DISCUSSION

Using quality improvement methodology to address a critical community need, we implemented food insecurity screening across a hospital system including multiple sites and specialties and provided critical resources to households in need.

Critical examination of resilience and resistance in African American families: Adaptive capacities to navigate toxic oppressive upstream waters

African American families navigate not only everyday stressors and adversities but also unique sociocultural stressors (e.g., "toxic upstream waters" like oppression). These adverse conditions are consequences of the historical vestiges of slavery and Jim Crow laws, often manifested as inequities in wealth, housing, wages, employment, access to healthcare, and quality education. Despite these challenges, African American families have developed resilience using strength-based adaptive coping strategies, to some extent, to filter these waters. To advance the field of resilience research, we focused on the following questions: (1) what constitutes positive responses to adversity?; (2) how is resilience defined conceptually and measured operationally?; (3) how has the field of resilience evolved?; (4) who defines what, when, and how responses are manifestations of resilience, instead of, for example, resistance? How can resistance, which at times leads to positive adaptations, be incorporated into the study of resilience?; and (5) are there case examples that demonstrate ways to address structural oppression and the pernicious effects of racism through system-level interventions, thereby changing environmental situations that sustain toxic waters requiring acts of resilience to survive and thrive? We end by exploring how a re-conceptualization of resilience requires a paradigm shift and new methodological approaches to understand ways in which preventive interventions move beyond focusing on families' capacity to navigate oppression and target systems and structures that maintain these toxic waters.

Clinical Pathways for the Identification and Referral for Social Needs: A Systematic Review

CONTEXT

Recognition of the importance of the social determinants of child health has prompted increased interest in clinical pathways that identify and refer for social needs.

OBJECTIVE

The aim of this systematic review was to determine the effectiveness of interventions that identify and refer for social needs for families with children aged 0 to 18 years attending outpatient community and ambulatory healthcare services.

DATA SOURCES

We searched the following databases: Medline, Embase, PsychINFO, CINAHL, Emcare, EBMR.

STUDY SELECTION

Studies were included if children and their families underwent a process of identification and referral for social needs in outpatient community and ambulatory healthcare services.

DATA EXTRACTION

Initial searches identified 5490 titles, from which 18 studies (73 707 families and children) were finally retained.

RESULTS

Intervention pathways were grouped into 3 categories based on whether identification and referral for social needs was conducted with only targeted community resources, a navigator, or with clinician training. The majority of studies reported positive outcomes; with an increase in social needs identification, an increase in referrals following identification, or a reduction in social needs. Child health outcome results were inconsistent.

LIMITATIONS

The search terms used may have provided bias toward countries in which these terms are in use. The heterogeneity of outcome measures between included studies meant a meta-analysis was not possible.

CONCLUSIONS

Despite evidence that clinical pathways for children and families help reduce social needs, evidence for improvements in child health is insufficient. Further studies from diverse settings are needed to inform clinical practice to optimize child health outcomes.

Early Childhood Referrals by HealthySteps and Community Health Workers

This study explored how a community health worker (CHW) within a primary care team with a HealthySteps (HS) Specialist impacted referrals to social determinant of health resources for families with children aged birth to 5 years. Medical charts with documentation of HS comprehensive services between January and June 2018 were reviewed at 3 primary care clinics: 2 with an HS Specialist (HSS Only) and 1 with an HS Specialist and CHW (HSS + CHW). Eighty-six referrals were identified, 78 of which had documented outcomes. Outcomes were categorized as successful, unsuccessful, and not documented. The HSS + CHW group had a higher rate of successful referrals (96%) than the HSS Only group (74%). Statistical analysis (χ² = 8.37, P = .004) revealed a significant association between the referral outcome and having a CHW on a primary care team with an HS Specialist. Therefore, primary care practices should consider adapting their HS model to include CHWs.

Social Needs Resource Connections: A Systematic Review of Barriers, Facilitators, and Evaluation

INTRODUCTION

Healthcare organizations increasingly are screening patients for social needs (e.g., food, housing) and referring them to community resources. This systematic mixed studies review assesses how studies evaluate social needs resource connections and identifies patient- and caregiver-reported factors that may inhibit or facilitate resource connections.

METHODS

Investigators searched PubMed and CINAHL for articles published from October 2015 to December 2020 and used dual review to determine inclusion based on a priori selection criteria. Data related to study design, setting, population of interest, intervention, and outcomes were abstracted. Articles' quality was assessed using the Mixed Methods Appraisal Tool. Data analysis was conducted in 2021.

RESULTS

The search identified 34 articles from 32 studies. The authors created a taxonomy of quantitative resource connection measures with 4 categories: whether participants made contact with resources, received resources, had their social needs addressed, or rated some aspect of their experience with resources. Barriers to resource connections were inadequacy, irrelevancy, or restrictiveness; inaccessibility; fears surrounding stigma or discrimination; and factors related to staff training and resource information sharing. Facilitators were referrals' relevancy, the degree of support and simplicity embedded within the interventions, and interventions being comprehensive and inclusive.

DISCUSSION

This synthesis of barriers and facilitators indicates areas where healthcare organizations may have agency to improve the efficacy of social needs screening and referral interventions. The authors also recommend that resource connection measures be explicitly defined and focus on whether participants received new resources and whether their social needs were addressed.

Screening for Adverse Childhood Experiences in Children: A Systematic Review

CONTEXT

Adverse childhood experiences (ACEs) are associated with increased risk of poor mental health outcomes. Although there is interest in screening for ACEs for early identification and intervention, it is not known whether screening improves outcomes for children.

OBJECTIVE

To systematically review whether screening for ACEs in children leads to an increase in (1) identification of ACEs, (2) referrals to services, (3) increased uptake of services, and (4) improved mental health outcomes for children and parents.

DATA SOURCES

Ovid Medline, PsycINFO, CINAHL, and Center for Clinical and Translational Research electronic databases were searched between 2009 and 2021.

STUDY SELECTION

Studies were included if researchers screened for current ACEs in children aged 0 to 12 years and they had a control comparison.

DATA EXTRACTION

Information was extracted, including study characteristics, sample demographics, screening tool characteristics, referral rates to services, uptake rates, and mental health outcomes.

RESULTS

A total of 5816 articles were screened, with 4 articles meeting inclusion criteria. Screening for ACEs increases identification of adversity and may increase referrals to services. There are limited data about whether this leads to an increase in referral uptake by families. There are no reported data addressing mental health outcomes.

LIMITATIONS

There are few published control trials of moderate quality.

CONCLUSIONS

There is limited evidence that screening for ACEs improves identification of childhood adversity and may improve referrals. If we are to realize the hypothesized benefits of ACEs screening on child and parent mental health, it is essential to understand the barriers for families taking up referrals.

Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force

IMPORTANCE

Evidence-based guidance is limited on how clinicians should screen for social risk factors and which interventions related to these risk factors improve health outcomes.

OBJECTIVE

To describe research on screening and interventions for social risk factors to inform US Preventive Services Task Force considerations of the implications for its portfolio of recommendations.

DATA SOURCES

Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts (through 2018); Social Interventions Research and Evaluation Network evidence library (January 2019 through May 2021); surveillance through May 21, 2021; interviews with 17 key informants.

STUDY SELECTION

Individual-level and health care system-level interventions with a link to the health care system that addressed at least 1 of 7 social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, interpersonal safety, education, and financial strain.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data from studies and a second investigator evaluated data abstractions for completeness and accuracy; key informant interviews were recorded, transcribed, summarized, and integrated with evidence from the literature; narrative synthesis with supporting tables and figures.

MAIN OUTCOMES AND MEASURES

Validity of multidomain social risk screening tools; all outcomes reported for social risk-related interventions; challenges or unintended consequences of screening and interventions.

RESULTS

Many multidomain social risk screening tools have been developed, but they vary widely in their assessment of social risk and few have been validated. This technical brief identified 106 social risk intervention studies (N = 5 978 596). Of the interventions studied, 73 (69%; n = 127 598) addressed multiple social risk domains. The most frequently addressed domains were food insecurity (67/106 studies [63%], n = 141 797), financial strain (52/106 studies [49%], n = 111 962), and housing instability (63/106 studies [59%], n = 5 881 222). Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care. Thirty-eight studies (36%, n = 5 850 669) used an observational design with no comparator, and 19 studies (18%, n = 15 205) were randomized clinical trials. Health care utilization measures were the most commonly reported outcomes in the 68 studies with a comparator (38 studies [56%], n = 111 102). The literature and key informants described many perceived or potential challenges to implementation of social risk screening and interventions in health care.

CONCLUSIONS AND RELEVANCE

Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.