What composes one’s overall health?
“Like they say, it’s not about your genetic code,” says pediatric emergency medicine specialist Dr. Rammy Assaf. “It’s more about your zip code.”
Twenty percent of a person’s health is dictated by genes and other medical factors, Dr. Assaf explains. The other 80 percent has to do with social factors – including where one lives, learns, works, and plays, as well as available resources.
Because of this, inequities in healthcare persist, with people facing food insecurity, a lack of stable housing, poverty and other challenges experiencing poorer health outcomes compared to their more advantaged counterparts.
CHOC now finds itself at the head of a growing movement in pediatric healthcare nationwide to address health-related social needs (HRSN) by screening patients and families who come to the Julia and George Argyros Emergency Department at CHOC Hospital, and, if they indicate needs, direct them to resources.
Until now, such screening has existed in some form – for example, the CHOC ED instituted a universal screen for homelessness in 2022 – but there has been no uniform, standardized, participant-informed process.
Dr. Assaf and his team are implementing one.
QR-code accessible tool
Since early December 2023, patients’ families who come to the CHOC ED as well as its Wellness on Wheels (WoW) mobile health clinic have been asked to use a QR-code based self-screening tool for eight common and basic family-centered needs: food, housing, bills/utilities, transport, mental health, support, healthcare access, and conflict.
If the family indicates an urgent need, an assigned social worker receives an immediate email and calls the family within three business days to help navigate them through eligible community services and resources. The social worker also calls the family a few weeks later to assess any ongoing challenges in meeting their areas of need.
The goal, Dr. Assaf says, is to roll out the screening tool throughout the CHOC enterprise after he and his team assess how it’s working. The tool could serve as a national model for other pediatric healthcare systems, he notes.
“This represents a cutting-edge approach to clinical integration of social care, based on a decade of evidence-based best practices,” Dr. Assaf says. “And we’re not just trying to identify the social factors that affect a person’s health, but the root causes of these social factors.”
Social care comprises interventions that identify and assist with adverse social circumstances.
“This is an exciting project that will be a fabulous resource for CHOC families,” says Dr. Theodore Heyming, medical director of pediatric emergency medicine at CHOC.
Responses to the screening tool are securely stored on REDCap, although one day may go directly to the patient’s EMR (electronic medical record).
A safety net
Beginnings of the social needs assessment tool (or “SNAT”) date back to October 2022 when Dr. Assaf and CHOC Research Institute senior biostatistician Lois Sayrs, Ph.D., interviewed a diverse group of eight key CHOC clinical leaders regarding the current state of screening for social determinants of health (SDOH).
Although there has been a considerable amount of screening that CHOC has instituted since 2019, Drs. Sayrs and Assaf concluded based on their interviews that screening was siloed and inconsistent, with limited family follow up and unorganized data.
“This scenario, which many other healthcare organizations face, makes it difficult to bring about progressive and sustainable change,” Dr. Assaf says.
Such a program could potentially improve access to resources and decrease social inequities.
Dr. Assaf and two field expert co-authors based at Boston Medical Center and Nationwide Children’s Hospital published their views on a sustainable approach to social care in JAMA Pediatrics. Collaboration with these experts in other parts of the country also helped shape the design of the screening tool.
Unmet HRSN are correlated with poverty, are common among households with children, disproportionately affect people of color, and increase reliance on emergency and hospital care, according to the JAMA Pediatrics report, “Sustainably Implementing Social Determinants of Health Interventions in the Pediatric Emergency Department.”
The ED is an ideal place to start with the screening tool, Dr. Assaf said, given its around-the-clock accessibility and safety net functions for the delivery of medical care.
However, the ED also faces its own set of unique challenges to systematically integrating screening, such as high patient volume and acuity as well as wide staff turnover in a shift work model. Dr. Assaf believes that the ED is only one piece of a wider fabric of social care, which should have multiple access points across a healthcare organization.
A successful model
A key component of the screening tool was adapted from a successful model implemented at Nationwide Children’s Hospital in Columbus, Ohio, in which families were asked to indicate the urgency of their social need.
Social workers who called families with urgent need found that their workload did not significantly increase once the tool was implemented, Dr. Assaf added.
He also took note that historically, while healthcare providers and families value social care, limited provider time and training are consistent barriers to success.
Families tend to disclose more social need when using digital modalities, as opposed to face-to-face screening, highlighting the potential stigma associated with screening.
Social workers have been identified as the providers best positioned to help navigate families through eligible community resources.
Breaking down barriers
Dr. Assaf, who grew up in La Crescenta, began at CHOC full time in 2022, but also spent time here during his pediatric emergency medicine fellowship, beginning in 2019.
Even before he was a medical student at the University of Miami, he was interested in social science and that is the lens through which he continues to practice medicine.
He earned a master’s degree in international affairs in Geneva, Switzerland, where he also worked for the World Health Organization (WHO). His focus included global health diplomacy and indigenous people’s rights.
He earned a dual MD-MPH degree in Miami, where he also worked with artists and community leaders in a project to promote intergenerational messages around chronic disease prevention in the historically disenfranchised city of Overtown.
“Medicine is a tool for collaboration and a way to break down barriers,” Dr. Assaf says.
As a pediatric resident, he helped build from the ground up a community help desk in the Children’s Hospital Los Angeles ED. Then, as a pediatric emergency medicine fellow at Harbor UCLA, he published a finding that patients prefer using their mobile phones to disclose social needs as opposed to other modalities such as tablet computers or paper.
Making a difference
Working closely with Dr. Assaf in launching the SNAT is Erika Jewell, LCSW, manager of case management and social services at CHOC.
The goal is that the SNAT eventually will replace an existing screening tool used by CHOC and other pediatric healthcare systems called PRAPARE, for Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.
The PRAPARE tool, Dr. Assaf says, is considered very cumbersome to use, for both families and social workers.
The SNAT isn’t, he adds. It takes about a minute to complete and is available in Spanish and English.
“It’s designed to serve the largest number of people possible and to make the biggest difference possible, without interrupting an already strained clinical workflow or adding to the social worker’s plate,” Dr. Assaf noted.
“It’s also delivered in a way that is adaptable across clinical settings and users (families) provide direct feedback on the content and process of the SNAT,” Dr. Assaf adds.
“A lot of thought was put into the development of this brief set of questions,” Erika notes. “We looked at local statistics and collected data from over 3,500 PRAPARE screenings done by CHOC social workers to make sure we captured the more significant and frequently cited social needs.
“Our bilingual, bicultural social workers and parents of CHOC patients reviewed the tool to make sure it would be acceptable and easy to understand. The good news is that Orange County has resources to help patients and families who have these needs.”
Proof of concept
Dr. Assaf and his colleagues currently are conducting a proof-of-concept study to see if the screening tool will work throughout the CHOC enterprise. He expects the study to be completed by this fall.
“Collaboration, evidence-based practice, and sustainability are the three core tenets of our project,” Dr. Assaf says.
Dr. Michael Weiss, vice president of population health at CHOC, says CHOC defines “health” broadly to include physical, mental, emotional, social and academic domains.
“The excellent work Dr. Assaf and Erika are leading complements our outstanding medical care by assuring we also address the 80% of what makes our patients healthy,” Dr. Weiss says.
Learn about pediatric research and clinical trials at CHOC
