Doctors Screening Families for Social Determinants of Health
By Beth Truzansky
Every child deserves a bright future. Perhaps that is why so many children-supporting agencies and organizations include the phrase “Bright Futures” in their titles, like Building Bright Futures, the Child Development Division’s Bright Futures Information System, and the American Academy of Pediatrics (AAP) Bright Futures Guidelines for pediatricians.
Parents, doctors, childcare providers, teachers, and other social service providers all want to lay a solid path for children to thrive from birth throughout their development. New recommendations from the American Academy of Pediatrics have doctors asking questions of parents to understand what environmental factors may threaten a child’s ability to thrive and then work with families to get additional supports.
As a Regional Coordinator with Building Bright Futures, I work to coordinate the many different services for children and families across Chittenden County, including hospitals, schools, home visitors, childcare providers, and town planning. In each region in Vermont there are people working at the regional and state level to coordinate, make improvements, and advocate for changes to our early childhood system.
This year Building Bright Futures is partnering with the American Academy of Pediatrics Vermont Chapter to convene regional conversations about the health of our children and introduce a new edition of the Bright Futures guidelines, which guide Pediatricians in what to ask about social determinants of a child’s health during annual well-child visits. These conversations bring both pediatricians and the community based providers together through dinner forums across the state.
The Chittenden County forum will be on March 28; forums have already occurred at Burke Mountain (Northeast Kingdom, St Johnsbury, Waterbury, (Lamoille and Washington Counties), and Bellows Falls (Brattleboro and Springfield) with Bennington, Middlebury, Rutland, St. Albans, and White River Junction area to be scheduled.
The exciting addition to the updated Bright Futures Guidelines is that Pediatricians are now asking all families questions like,
“Within the last 12 months, have you worried your food would run out before you got money to buy more?”
“What is your housing situation today?”
“What do you do when problems at home really get to you? Who do you turn to in times like that?”
These are all questions that go beyond a child’s development or health concerns, and get to the quality of the family and physical environment.
Dr. Breena Holmes is the Director of Maternal and Child Health with the Vermont Department of Health.
She reflects, “There was one time in healthcare when we thought a developmental delay was due to genetics. It took a time to recognize delays are also due to the environment in which a child is living. Issues of housing, mental health or stress on families, including lack of affordable child care, impact a child’s brain development.”
Pediatricians asking families about social factors, including housing, food security, or emotional supports is a step to engage the full range of factors influencing a child’s wellness.
“Pediatric care is an entry point to figure out what is happening with our families and how we will work together,” says Holmes.
The Bright Futures Guidelines affirm that, “health starts in our homes, schools, workplaces, neighborhoods, and communities.” Our health is influenced both by biologic and social factors.
Biologic determinants of health include: How we take care of ourselves, what we eat, our behaviors, as well as stress caused by lack of money to buy groceries, or living in a home that has mold or other toxins. And the guidelines state, “our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be.”
Healthcare is an ideal setting to provide parenting support. 95% of Vermont infants receive routine health care with a child health provider in the first month of life. Because most people go regularly, the doctor’s office does not have the same social stigma as other settings. Plus, parents trust their doctor’s guidance so it is logical for healthcare settings to formalize their process to ask about both biologic and environmental impacts, as well as connect families to resources they need.
“I’m excited about the focus of social determinants of health and strengthening families. That’s where the joy in pediatrics is; to give families the tools they need as their child develops. I want to help them be the parents they want to be” shared Dr. Jill Rinehart of Hagan, and Connolly Pediatric practice in Burlington.
Healthcare providers can’t do this alone. Asking families about their stressors at home is a start, but the Bright Futures guidelines recognize that families ultimately need more support and it partnerships between health care offices and other community-based service providers that will support families through hard times.
“My primary vision is that the human service field is placed in health service world.” says Holmes, “the idea is to normalize screening and provide a human bridge to community resources through a family specialist staff person embedded in the healthcare setting.”
Embedding Social Workers, Care Coordinators, or Family Support workers in healthcare settings is starting to happen in part due to changes in healthcare funding. While this is ideal, staff capacity is limited. Rinehart says that while Hagan, Rinehart and Connolly serves many children; there is a Social Worker on staff who is only available four hours a week helping families connect with services.
An alternative solution is Help Me Grow which is a resource for expectant parents and families with young children. Anyone can call, including parents, nurses or childcare providers. Help Me Grow has two Child Development Specialists who receive calls with questions about child development, parenting, or when people have questions and don’t know where to go for support. The number to Help Me Grow is 211 x 6 or text 898122.
Asking families about social determinants and then making connections to services is already in practice in Vermont and working to improve the lives of children and families. “Just recently I had a family who welcomed the third child to the family. With three children under three, the family made the decision for Mom to stay home with the children and not return to work. During the doctor’s visit, Mom screened positive on food insecurity sharing she was concerned about feeding her family. She was able to get support from our social worker to see what benefits the family could access. We found that while the family was ineligible for Medicaid (they made just $200 too much each month to qualify) they did qualify for WIC. This is a classic example of a family falling through the cracks and not having enough money to support their family and they are not alone. There are a surprising number of families on the edge. I think because of this new screening process, we a could identify the family’s need which opened a door for other supports.” shared Rinehart.
Asking families about social determinants and then making connections to services is already in practice in Vermont and working to improve the lives of children and families.
“Just recently I had a family who welcomed the third child to the family. With three children under three, the family made the decision for Mom to stay home with the children and not return to work. During the doctor’s visit, Mom screened positive on food insecurity sharing she was concerned about feeding her family. She was able to get support from our social worker to see what benefits the family could access. We found that while the family was ineligible for Medicaid (they made just $200 too much each month to qualify) they did qualify for WIC. This is a classic example of a family falling through the cracks and not having enough money to support their family and they are not alone. There are a surprising number of families on the edge. I think because of this new screening process, we could identify the family’s need which opened a door for other supports.” shared Rinehart.
How do we improve the lives of kids and families by asking these new questions and focusing more on social determinants of health in addition to biologic?
Holmes reflects, “For me it’s about early detection. The sooner we, as doctors, know what is happening with our families, the sooner we can support them. There are kids we meet where we wish we knew more about their environment. Isn’t that what you think about the school shootings? ‘I wonder, what happened to those boys?’ What were his first five years like? The hope is we use the access of new baby check ups as a way to normalize screening and then create the bridge to community supports. As doctors in partnership with parents, we want to be ahead of brain development and mitigate things as early as possible.”
Chittenden Regional Coordinator
Building Bright Futures