Review Article

From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice Fatima Fazalullasha (H)BHSc1,2, Jillian Taras MSc BSc3, Julia Morinis MSc MD4, Leo Levin MD1,5, Karima Karmali MBA6, Barbara Neilson MSW7, Barbara Muskat RSW PhD7, Gary Bloch MD8, Kevin Chan MD9, Maureen McDonald RECE MEd10, Sue Makin11, E Lee Ford-Jones MD1 F Fazalullasha, J Taras, J Morinis, et al. From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice. Paediatr Child Health 2014;19(4):195-199. Previous research has highlighted the importance of addressing the social determinants of health to improve child health outcomes. However, significant barriers exist that limit the paediatrician’s ability to properly address these issues. Barriers include a lack of clinical time, resources, training and education with regard to the social determinants of health; awareness of community resources; and casemanagement capacity. General practice recommendations to help the health care provider link patients to the community are insufficient. The objective of the current article was to present options for improving the link between the office and the community, using screening questions incorporating physician-based tools that link community resources. Simple interventions, such as routine referral to early-year centres and selected referral to public health home-visiting programs, may help to address populations with the greatest needs. Key Words: Health care delivery; Paediatrics; Social determinants of health

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he social determinants of health (SDOH) are the conditions in which people are born into, grow, live, work and age (1). SDOH include early childhood development, education, employment and working conditions, family income, food security, housing, health care services, social support, neighbourhood safety, inequities among economic groups and racism (1-3). Marginalized individuals experience the highest levels of disease and premature death (1,2). Approximately 15% to 19% of Canadian children live in poverty and are more likely to experience low birth weight, learning difficulties, mental health problems, iron deficiency anemia, asthma, burns and injuries, obesity and hospitalization than their more affluent peers (4,5). Exposure to prolonged stress (known as toxic stress) negatively impacts the development of the neuroendocrine-immune system (6). Infants living in poverty have a 60% higher mortality rate (2). Children are particularly vulnerable because they are dependent on their families for basic needs, social support, socialization and life skills (7). The number of social risk factors and length of exposure demonstrate a cumulative and increased vulnerability to poorer health status over the years, which impact ‘life-course developmental health’ (6-8).

Des outils en cabinet à l’appui communautaire : la nécessité d’une infrastructure pour tenir compte des déterminants sociaux de la santé en pédiatrie Des recherches antérieures ont fait ressortir l’importance de tenir compte des déterminants sociaux de la santé pour améliorer la santé des enfants. Cependant, des obstacles importants empêchent les pédiatres de bien se pencher sur la question, incluant le manque de temps clinique, de ressources, de formation et d’enseignement sur les déterminants de la santé, la connaissance des ressources communautaires et la capacité de gestion des cas. Les recommandations faites en pratique générale pour aider le dispensateur de soins à orienter les patients vers des ressources communautaires ne suffisent pas. Le présent article vise à présenter des moyens de faire de meilleurs liens entre le cabinet et la communauté, à l’aide de questions de dépistage intégrant des outils médicaux qui dirigent les patients vers des ressources communautaires. Des interventions simples, telles que l’orientation systématique vers des centres de la petite enfance et l’orientation sélective vers des programmes de visite à domicile par la santé publique, peuvent contribuer à servir les populations qui ont les besoins les plus criants.

Although awareness is increasing, a significant proportion of paediatric patients and their families have unidentified or poorly managed psychosocial concerns (9-11). Barriers for physicians to address the SDOH include a lack of time, resources, training, awareness of community resources and case management capacity to promote change (12). Additionally, the SDOH have a disproportional burden on immigrant families, emphasizing the importance of providing culturally competent care (9). The American Academy of Pediatrics recommends expanding the role of paediatric providers to include screening, assessment and referral of parents for social problems (7). There must be greater focus on implementing a practical, synergistic and systematic approach for clinicians that includes the following: • screening directed at the broader needs of patients; • provision of referral to appropriate resources; • assured follow-up and support. To achieve this, a virtual or real service navigator, case manager or health advocate may be required (12). Several innovative initiatives from the development of screening tools and community resources to comprehensive hospital- and clinic-based programs that attempt to address these disparities will be reviewed.

1Social

Pediatrics, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto; 2Faculty of Medicine, University of Ottawa, Ottawa; 3Faculty of Medicine, University of Toronto; 4Departments of Pediatric Medicine, The Hospital for Sick Children; 5The Children’s Aid Society; 6Child and Family Relations Center for Innovation and Excellence in Child and Family-Centered Care, The Hospital for Sick Children; 7Department of Social Work, The Hospital for Sick Children and University of Toronto; 8Family Medicine; 9Department of Emergency Medicine, The Hospital for Sick Children and Munk Centre for Global Studies, University of Toronto; 10Mothercraft; 11Toronto Public Health, Toronto, Ontario Correspondence and reprints: Ms Fatima Fazalullasha, c/o Lee Ford-Jones, Social Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-5443, fax 416-813-7479, e-mail [email protected] Accepted for publication October 6, 2013

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Table 1 Social history domains for exploration using the ‘ITHELLPS’ mnemonic to address basic needs Domain/area

Examples of questions

Income General

Do you ever have trouble making ends meet?

Food income

Within the past 12 months did you worry whether your food would run out before you got money to buy more? Within the past 12 months did the food you buy last and did you have money to get more?

Transportation Public transportation

Do you have trouble paying for public transportation?

Long distance travels

Are you able to access basic needs from your home (ie, food, health services, job, school) in manageable time?

Housing Housing

Is your housing ever a problem for you?

Utilities

Do you ever have trouble paying your electric/heat/telephone bill?

Education Appropriate education placement How is your child doing in school? Is he/she getting the help to learn what he/she needs? Are you able to speak to the teacher and go to parent-teacher meetings? Does your child use the breakfast programs, have after-school programs at the school? Early childhood program

Do you go to the Early Years/Best Start Child and Family Centers? Does your child go to other preschool, or other early childhood activities?

Legal status Immigration

Do you have questions about your immigration status? Do you need help accessing benefits or services for your family?

Literacy Child literacy

Do you read to your child or tell stories around pictures in the book every night? Singing and speaking with your child as much as possible is really good too – are you able to do that?

Parent literacy

How happy are you with how you read?

Personal safety Domestic violence

Have you ever taken out a restraining order?

General safety

Do you feel safe in your relationship? Do you feel safe in your home? In your neighbourhood?

Support Personal

Do you have a close network of supportive family and friends?

Support services

Are you aware of social programs available to you? Do you use them?

Adapted from references 3 and 27

Novel Initiatives for Addressing the SDOH Improving screening methods The majority of information regarding the social circumstances of a child is collected through the social history. While the comprehensive HEADSS (home and environment, education and employment, activities, drugs, sexuality, suicide/depression) assessment is used in adolescent medicine, such questioning has often otherwise been limited (3). A useful mnemonic, ‘IHELLP’, revised here as ‘ITHELLPS’, is one method for physicians to comprehensively approach social history issues such as income and food security, transportation, housing/utilities, education, legal status/ immigration, literacy, personal safety and support (Table 1) (3). The original published mnemonic provides a coherent way to explore a breadth of SDOH that can readily link to available interventions such as legal support. Garg and Dworkin (12) recommend tailoring screening tools to the most commonly identified problems in the communities being served, while global screening tools can identify more basic family problems such as food and employment. They recommend conducting routine screening with initial intake, for newborns within the first six months, and regularly thereafter at well-child care visits. Screening should be increased according to the burden of psychosocial issues in the community (12). A novel Canadian (Ontario) screening tool encourages family physicians to ask ‘seven simple questions to help patients living in poverty’ with the purpose of linking patients to appropriate financial interventions (Table 2) (13). Their questions – eg, inquiring whether all patients have completed their tax forms, whether families with children receive the Child Benefit 196

each month, whether individuals with disabilities receive payments from various disability programs and whether social assistance recipients have applied for extra income supplements – are simple but high-yield steps toward helping patients achieve maximum support based on their individual needs. Once patients have been screened, they can be directed to specific resources to assist them in addressing their income security using the resources available on the tool (www.ocfp.on.ca/cme/povertytool). Furthermore, a novel Canadian paediatric poverty tool was developed at The Hospital for Sick Children (Toronto, Ontario), which parallels poverty screening questions to specific community resources (14). Screening is an essential first step in addressing the SDOH. It provides a foundation for physicians to understand the family context, and also helps to direct their patients to appropriate interventions (3). Development of a standardized screening tool and more extensive training for physicians can help to incorporate SDOH into daily office practice. Improving methods of referral to appropriate resources Following screening, the patient should be connected to the appropriate resources and programs. The development of comprehensive community resource listings is imperative for meeting the needs of patients and their families, and enabling health care teams to provide appropriate referrals (Table 2). Many city wards provide a listing of local resources. In Toronto, the 211Toronto.ca resource provides a search engine for resources such as housing, low-cost dental services and family literacy centres (15); the 211 telephone service is provided by a live Resource Specialist year-round, 24 h per day, confidentially, unrecorded and in Paediatr Child Health Vol 19 No 4 April 2014

Addressing SDOH in paediatric practice

Table 2 Examples of national and local (Toronto, Ontario) resources

Table 2 – Continued Examples of national and local (Toronto, Ontario) resources

Concern

Where to refer

Concern

Benefits and support

Three easy-to-use guides to government benefits:

Where to refer Aboriginal Legal Services of Toronto

1. Service Canada: www.servicecanada.gc.ca

www.aboriginallegal.ca Safety

Assaulted Women’s Helpline

2. Canada Benefits: www.canadabenefits.gc.ca

Telephone 416-863-0511

3. Ontario Benefits Directory: www.ontario.ca/benefitsdirectory

Domestic violence women

Community income tax clinics www.cra-arc.gc.ca/tx/ndvdls/vlntr/clncs/on-eng.html, telephone 1-800-959-8281

Emergency shelters

Social support programs http://www.mcss.gov.on.ca/en/mcss/programs St. Christopher House for Financial Advice www.stchrishouse.org, telephone 416-848-7980 Disease-specific financial advice

www.schliferclinic.com, telephone 416-323-9149 Telephone 877-338-3398 Toronto Homeless Services www.toronto.ca/housing When you do not know where to turn: 2-1-1 (telephone) or 211ontario.ca. This is a free, complete directory of supports and services
in Ontario including housing, employment and other social supports. It is available 24 h/day, in 150 languages, and is confidential and unrecorded

Wellspring: www.wellspring.ca, for individuals with cancer. Persons with AIDS Foundation: www.pwatoronto.org, for individuals with HIV. Wellspring Money Matters Resource Centre www.wellspring.ca, telephone 416-961-1493. Cancer patients can access financial consultation and clinics. Income Security Advocacy Centre www.incomesecurity.org Local employment and social services www.toronto.ca/socialservices Access to food

Daily Bread Food Bank www.dailybread.ca, telephone 416-203-0050 School-based nutrition Breakfast for Learning: www.breakfastforlearning.ca Breakfast Clubs of Canada: www.breakfastclub.ca Start2Finish: http://start2finishonline.org

Prescription drug coverage

Ontario Drug Benefit Program www.health.gov.on.ca/en/public/programs/drugs/, telephone 416-314-5518, 800-268-1154 Trillium www.health.gov.on.ca/english/public/pub/drugs/trillium.html

Child benefits Service Canada www.servicecanada.gc.ca/eng/goc/cctb.shtml, telephone 800-622-6232 Canada Revenue Agency www.cra-arc.gc.ca/bnfts/menu-eng.html, telephone 800-387-1193. Search for and download RC66, Canada Child Benefits Application Legal and immigration clinics OCASI-Settlement www.settlement.org, telephone 416-322-4950 Community Legal Education Ontario www.cleo.on.ca, telephone 416-408-4420 Legal Aid Ontario www.legalaid.on.ca, telephone 416-979-1446, 800-668-8258 Access Alliance www.accessalliance.ca, telephone 416-324-8677 ARCH Disability Law Centre www.archdisabilitylaw.ca Advocacy Centre for the elderly www.advocacycentreelderly.org

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150 languages. Internet-based government resources, such as Canada Benefits (www.canadabenefits.gc.ca), Service Canada (www.servicecanada.gc.ca) and Service Ontario (www.ontario.ca/ serviceontario), offer user-friendly guides to government-run social support programs (16-18). However, identification and appropriate allocation of community services to patients is a challenge for many health care providers due to the overwhelmingly large number of services and potential barriers with regard to knowledge of existing programs (12). For example, a report found that community-based food initiatives reach only a very small proportion of low-income Toronto families characterized as food insecure or insufficient, and called for a more effective way for food-insecure families to reach community food resources (19). Further research is needed in this area to better understand how resources can best reach families in need. Development of comprehensive programs including screening, referral and follow-up The following review of three novel programs demonstrates management initiatives for primary care and hospital-based physicians. These initiatives require physicians to screen their patients, and refer either directly or indirectly, through case management workers or specialized volunteer services, to social supports. Overall, these programs are successful at addressing the SDOH for families using the three essential steps discussed above. First, Garg et al (20) conducted a randomized controlled trial involving 200 parents at an urban hospital-based paediatric clinic to evaluate the implementation of a psychosocial screening and referral program. The team developed a brief self-report survey written at the third-grade level in English, assessing 10 psychosocial issues (lack of high school education, unemployment, smoking, drug abuse, alcohol abuse, depression, intimate-partner violence, child care need, homelessness and food security) and the family’s motivation for addressing each issue. In the intervention group, parents of children two months to 10 years of age were asked to complete the questionnaire before their clinical visit and submit it directly to the resident during their appointment (20). The authors also developed a ‘family resource book’ containing information about available resources for the screened items, with copies available for families. Paediatric residents in the intervention group were trained and informed about the family resource book. Participants received a postappointment visit and onemonth follow-up interview to assess outcomes. Overall, the intervention group demonstrated statistically significant improvements 197

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in outcomes: families had discussed more psychosocial topics; there were fewer unmet needs for discussion during their clinic visit; more referrals were made for community resources (job training, housing, General Education Development classes, food resources, smoking cessation classes and child care); and there was a greater likelihood of contacting the resource. Moreover, approximately 90% of residents reported that the tool lengthened the visit by 23,000 patients. Families visit either a partner hospital or health centre where they are screened for basic needs such as food or heating. Patients then bring their prescriptions to the Health Leads Desk where college students, trained as health leads advocates, assess patients’ eligibility for health insurance, food pantries and food-assistance programs, gas and electric turn-off assistance and discounts, job training and daycare subsidies. Health Leads advocates help patients to navigate through the complexities of accessing resources by assisting them in finding telephone numbers, completing applications, finding transportation and printing maps (22). Third, in 2011, The Hospital for Sick Children conducted an in-hospital Settlement Services Pilot Program to gain an understanding of the barriers faced by newcomers (new immigrant and refugee families) in accessing quality health care and navigating the hospital, and to test an intensive case-management model in mitigating these barriers. For newcomers to Canada, language barriers combined with poor health literacy are significant impediments to access to health care (23). A registered nurse and social worker provided case management services. Thirteen families encompassing 26 children and 32 adults were referred to the program. The families came from ethnically, culturally and linguistically diverse backgrounds, and the children had a broad range of acute and chronic health conditions. A semistructured interview involving a needs and intake assessment was conducted with each family. Key needs were identified in the following areas: hospital navigation and wayfinding; understanding of diagnosis and treatment; financial assistance for medications and food; and anxiety about the child’s health. The interventions of the case management team included: advocating for appropriate resources (including medical interpreters); helping the families navigate the hospital and health care system; coordinating care; role modelling 198

and coaching families on how to have their voices heard in health care interactions; providing emotional support; and providing health education. Follow-up evaluation interviews with participants demonstrated that families had a better understanding of their child’s diagnosis and medical regimens, were able to access health care, community and government resources as a result of the services provided, and expressed a high degree of satisfaction with the case management support provided (24). These programs highlight key components essential for the effective management of SDOH: specialized screening and referral tools; strong community partnerships; adequate training of health care professionals and volunteers in managing the SDOH; and sound follow-up using physicians, case managers or volunteers, and continuous support programs. In addition, there needs to be support for cases that are more complex from a legal, mental health risk perspective. Building this link with community resources is critical for empowering families to overcome the SDOH and have better health outcomes (25,26).

RECOMMENDATIONS FOR ADDRESSING SDOH IN MEDICAL PRACTICE

Optimizing the health of children requires identification and effective management of psychosocial risk factors. Paediatricians are in a unique position to improve care of the entire family by partnering with family medicine, public health, nursing, social work and community services (7). An effective program requires approaches for screening, referral and follow-up. Development of an infrastructure supportive of medical management and addressing the SDOH is crucial to the success of holistic medical care. Physicians within an appropriate practice context have a responsibility to play a larger and more consistent role in addressing the SDOH through screening for needs, provision of appropriate referrals to resources, and assurance of follow-up and support. Addressing SDOH in office practice was reported as lengthening the interview by

From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice.

Des recherches antérieures ont fait ressortir l’importance de tenir compte des déterminants sociaux de la santé pour améliorer la santé des enfants. C...
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