The traditional healthcare model, or the “sick-care” system, was not designed to help prevent the onset of disease but instead to diagnose and treat illness providing a reactive and expensive system of medical care. In the US, this system costs multiple trillions of dollars yearly with poorer outcomes and is associated with shorter life expectancy than most other developed nations. These factors, along with an expanding body of research documenting that adverse childhood experiences (ACEs) defined as traumatic experiences occurring before the age of 18, are now known to have a dose-response association with later mental and physical health problems and are associated with damaging pathophysiologic “toxic stress” and epigenetic processes in childhood. This new knowledge is creating a paradigm shift in the medical system toward a new proactive model.
This new proactive system focuses on addressing suboptimal circumstances in which people are born, live, and work called Social Determinants of Health.
Proactive Healthcare Model through Screening for SDoH
Screening questionnaires can be used to determine the social determinants of health (SDoH) risk factors at the community or the individual level. At the individual level, healthcare settings use specific screening tools to assess and monitor the social needs and risk factors of patients. Hospital systems are increasingly attending to the Social Determinants that may be playing a role in proneness to readmissions and may use screening tests in this context. In contrast, proactive screening is aimed at preventing illness complications leading to care escalation and primary prevention to promote wellness.
Screening for social determinants of health can help to identify patients who may benefit from greater support in one or more areas, thus promoting whole-person care for the entire population, particularly for those who are marginalized and underserved. While there are many social determinants of health they often are divided into five core health-related social needs, which include housing, food, transportation, utilities, and personal safety.
Some of the available tools/questionnaires fall under these categories:
Family Challenges, Caregiver Depression, and Family Stressors
Family Assessment of Safety and Stress (FASS) and SEEK - PQ-R – screens for those risk factors most associated with later child maltreatment: parental depression, alcohol and substance use, intimate partner violence, major stress, food insecurity, and caregiving stress and harsh punishment of the child. Caregivers of children ages 0 – 5.
FASS Plus and SEEK-PLUS (F/U with barriers) – It is well known that individuals with the above risk factors are often ambivalent about getting help. Motivational interviewing (MI) is well established as a means to move patients to seek behavioral change. Since MI requires extra time during a visit CHADIS has created follow-ups to positive screens to Jumpstart an MI conversation. As above FASS and SEEK also ask about the adequacy of help being received and barriers to getting help for use in motivational interviews to encourage referral. These “Plus” tools can be used with patient-specific automated teleprompter and graphic conversation assistance and related post-visit messaging via CHADIS Patient Specific Templates or PST’s. Caregivers of children ages 0 – 5.
Edinburgh Postnatal Depression Scale (EPDS) - Widely-used tool for the assessment of postpartum depression. Adults 0-6 months postpartum
Health Screening – SoDH - screen for SDoH including insecurity in food, housing, transportation plus intimate partner violence and questions about urgency and desire for help.
Home and School Environment (Social History) - Child's social history including home and school environment details - Ages 0-21
The Hunger Vital Sign - US Household Food Security Scale to identify young children in households at risk of food insecurity.
PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences - Collects the data on patient social determinants of health.
Multidimensional Scale of Perceived Social Support (MSPSS) - Screener for assessment of an adult’s social support from family, friends, and significant other.
Protective Factors Survey (PFS) - designed for use with caregivers receiving child maltreatment prevention services such as home visiting, parent education, and family support. Measures protective factors in five areas: family functioning/resiliency, social support, concrete support, nurturing and attachment, and knowledge of parenting/child development.
Psycho-social Screener - A brief questionnaire regarding psychological and social issues that can affect the child and their family.
Patient Health Questionnaire 4 (PHQ-4) - very brief measurement of depression and anxiety.
PRIME-MD PHQ-2 – Two-item adult depression screening
Youth Health Questionnaire - Parent - assesses the perception of the child's risks, strengths, and challenges and the parent's perception of SDoH-related stability. Identifies families that may need assistance with relationship dynamics, and SDoH-related issues.
Childhood Experiences
Adverse Childhood Experiences (ACE) - Assesses adults’ adverse experiences in childhood before age 18.
Positive Childhood Experiences (PCE) - Questionnaire about positive events during the parent's own childhood before age 18. Items are appropriate to carry forward to current parenting and better predict current family stressors than ACE.
Adverse Childhood Experiences Questionnaire (ACE-Q) - Questionnaire about adverse events during childhood. For parents of children 0-12 years. There is also a teen version.
PEARLS: Pediatric ACEs and Related Life Events Screener - The PEARLS screens for a child’s exposure to Adverse Childhood Experiences (ACEs) and other potential risk factors for toxic stress (bullying, community violence, food or housing insecurity, etc.) that may increase a child’s risk for negative health outcomes.
Substance Use, Substance Use Exposure
Alcohol Use Disorders Identification (AUDIT-C) Test—Consumption – an alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence.
Cannabis Use Disorders Identification Test-Revised (CUDIT-R) - The CUDIT-R is a short tool to assess cannabis misuse in the past six months.
CEASE Questionnaire - Screens parents for household tobacco use and provide smoking parents with an action sheet including access to a telephone quit line.
CRAFFT - Substance use screener for adolescents. It covers alcohol and other drugs, nicotine including from vaping.
CRAFFT Interactive- Substance use screener for adolescents. It covers alcohol and other drugs, nicotine including from vaping. Included interactive educational information and vignettes about the facts and risks of substance use. Follow-up questions when positive assess reasons for or against using to be considered in a motivational interview as well as a nicotine addiction screen.
Drug Abuse Screening Test 10 (DAST) - screening test for substance abuse
Drug Abuse Screening Test 10 (DAST) and AUDIT - screening test for substance abuse and alcohol abuse
GPRA Behavioral Health Form Client/Staff/Office - assessing negotiated target goals
Relationships, Intimate Partner Violence
Conflict Tactics Scale - Screens for parental methods of child punishment. The most widely used tool for screening for physical abuse or neglect.
Hurt, insulted, Threatened with Harm, and Screamed (HiTS) - A domestic violence screening tool.
McMaster Family Assessment Device - a general assessment of family functioning.
Partner Violence Screen (PVS) - screen for domestic violence
Revised Dyadic Adjustment Scale - a tool to assess the quality of marital relationships.
Food Insecurity
The Hunger Vital Sign - US Household Food Security Scale to identify young children in households at risk of food insecurity.
By using smarter, more proactive methods, healthcare providers can be more efficient and provide equal care to all. To this point, technology is key. There are several platforms and tools available in the marketplace that allow healthcare providers to systematically screen their patients for social needs and to identify resources. CHADIS is just one example of these platforms. CHADIS allows providers to use any of the above tools in English or Spanish and integrate results directly into compatible EHRs. It also assists in the coordination of care and allows more effective information sharing between multiple sources to provide better tracking of outcomes.
As noted, CHADIS can help identify SDoH with options for clinical process support: identifying potential barriers to getting help; support for patient-specific motivational interviewing including suggested wording; clinician MOC-4 credits for quality improvement; post-engagement messaging.
Tracking outcomes: connection with local resources through a simple “refer button”; tracking outcomes with patient feedback - together comprising an entire system of care which also generates population metrics.
Helpful links:
https://www.site.chadis.com/social-determinants-of-health
https://www.cdc.gov/socialdeterminants/index.htm
https://pharmacy.unc.edu/wp-content/uploads/sites/1043/2020/02/SDoH-Report.pdf
Resources:
findhelp (www.findhelp.org) is a free online social services search engine. It connects people in need to programs in their community. The site lists available social services, including food, housing, transportation, health care, finances, education, employment, legal aid, and goods/ supplies (e.g., baby supplies, and clothing). The services are based on ZIP code and allow for electronic referrals.
UniteUs.com (www.uniteus.com) free online social services search engine. It connects people in need to programs in their community. The site lists available social services, including food, housing, transportation, health care, finances, education, employment, legal aid, and goods/ supplies (e.g., baby supplies, and clothing). The services are based on ZIP code and allow for electronic referrals.
*See the full list of questionnaires at: https://www.site.chadis.com/questionnaires