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Screening and Referring for Unmet Social Needs in the Pediatric Emergency Department: A Pilot Study in San Francisco


Background: Unmet social needs (USN) are defined as a privation of basic resources or services (e.g., a lack of food or medicine) that contributes to adverse health effects. Screening for USN in healthcare settings is an increasingly common strategy to connect patients and families with social assistance services. Some studies suggest that people with USN are more likely to seek healthcare services at the emergency department (ED) than those without USN. Screening and referral for USN in the pediatric emergency department (PED) may be a useful approach to help alleviate the health burden of USN on families and children. Purpose: The primary aim of this pilot study was to evaluate feasibility and acceptability of USN self-screening (i.e., self-initiated and self-completed USN screening) and self-referral at a single academic PED in San Francisco. Secondary aims were to estimate the proportions and demographics of PED patients and caregivers with USN and to describe the types of reported USN. Design: This pilot study used a quasi-experimental, single-group, survey design. Methods: Patients and caregivers presenting to the PED were first screened by PED nurses for emergent USN (i.e., expected lack of food or housing within the following 48 hours). PED nurses then facilitated administration of a self-report digital or paper USN survey that assessed six domains of non-emergent USN: concern for lack of food, housing, utilities, medications, healthcare transportation, or interpersonal safety within the following four weeks. Demographic information was collected from survey participants. Referral information for 211, a social assistance service staffed 24/7 by resource specialists, was provide to all participants. Those with emergent USN were offered a consult with the PED social worker. A follow-up survey was sent to participants two weeks after discharge from the PED to assess the status of USN, use of resources, and perceptions about usefulness. Survey response data was analyzed using Chi-square tests of independence, Fisher’s exact tests, and descriptive statistics. Field notes were used to identify themes related to the acceptability and feasibility of the intervention. Results: The USN self-screening and self-referral intervention was impeded by several barriers to feasibility and acceptability, including inadequate integration with the PED workflow and a lack of patient or caregiver willingness to engage with USN self-screening. In addition, some nurses described being ambivalent about how USN screening fit with their role or were uncertain about discussing USN screening with patients and caregivers. Only 1.6% (n=111) of the estimated 6,771 eligible individuals seen in the PED completed the USN survey. Of the 111 participants who completed the USN survey, 13.5% (n=15) endorsed at least one USN. Emergent needs were reported by 3.6% (n=4) of respondents. The two most frequently reported USN were utilities (80.0%, n=12) and food (73.3%, n=11). Participants were more likely to endorse USN if they were single, had lower income, or had lower levels household education compared to participants who were married or partnered, had higher income, or had higher levels of household education. Respondents who identified as Black, Indigenous, People of Color, (BIPOC) or Hispanic were more likely to report USN compared to White-identifying respondents. Of the five respondents who endorsed USN during the study period and completed the follow-up survey, four used either 211 or PED-provided resources. Insufficient data precluded determination of participant acceptability. Conclusion: Additional research is needed to determine acceptability and feasibility of nurse-facilitated, multi-domain, non-emergent USN screenings and surveys in the PED. In this pilot study, screening implementation and survey enrollment barriers were major obstacles to USN identification. These barriers were related to inadequate workflow integration, discretionary screening and survey enrollment practices, and indeterminate acceptability of nurse-facilitated USN screening. There also appeared to be a lack of interest or willingness to engage with self-screening among the PED population. Given the lack of outreach and engagement associated with discretionary self-initiated USN screening in this PED, USN initiatives in the PED may want to explore universal staff-initiated screenings in order to improve the likelihood of USN identification. Self-referral was reported by some participants as effective at helping them meet their USN, but there was insufficient data to determine whether self-referral reliably decreased USN. The substantial loss to follow-up of participants with USN suggested participants might have benefitted from automated referral systems or in-person resource navigation that would have allowed for improved service and follow-up capabilities.

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