As the Regional Coalition to Eliminate Race-Based Medicine aims to address health inequities by removing race from clinical decision making, one of the group’s institutions seeks to further advance those efforts by focusing on root causes and social drivers of health.
“If we don’t take time to find what’s happening beneath the surface with every child, we risk missing unmet needs,” said Rachel Thornton, MD, PhD, vice president and chief health equity officer at Nemours Children’s Health.
However, unconscious biases within health care can lead to differential treatment of patients based on race, potentially impacting the recommendation or delivery of health screenings, Thornton said. “The risk we run when labeling certain racial groups is very similar to the risk posed by racial differences in clinical algorithms. Our biases might lead us to make assumptions about certain populations and their levels of need."
The impacts of social drivers of health on pediatric patient populations don’t cut neatly across racial lines. Thornton referenced the fact that around 40% of all U.S. children are insured through Medicaid. She said one way to effectively eliminate race from medical screening is universal application. “Instead of magnifying perceptions and stereotypes about certain subgroups of patients, we're identifying universal needs among kids from all different walks of life,” she said.
Nemours Children's set out to optimize their screening process for social drivers of health to avoid any bias in the questions. Over several years, the hospital gathered patient family feedback and input from a multidisciplinary clinical team to develop a thorough screener that could fit within the time constraints of a typical patient visit. The streamlined questionnaire now includes 10 questions across 5 social health domains, including:
- Housing.
- Transportation.
- Household Safety.
- Food Insecurity.
- Financial Insecurity.
Since the new screening launched, Nemours Children’s has continued to collect insights from teams regarding the ease and relevance of screening as they look to scale social needs screenings to more sites across the system. Since 2022, they completed more than 135,000 patient screens with 13-14% having identified at least one need.
Challenges to interventions
Effectively addressing those needs is paramount to building a foundation of health with families.
“If you don’t respond properly, you undermine the patient/provider relationship,” Thornton said. “People feel like they’re baring their family’s most intimate vulnerabilities but don’t see what happens with that information.”
As such, the Nemours team analyzed the resource needs common to families across all geographies they serve. Through expansions of Nemours Cares Closets in Delaware Valley and the launch of a family resource center at Nemours Children’s Orlando, teams across the system bolstered readiness where deficiencies existed — for example, adding food, supplies, and other immediate tangible resources in clinics.
Still, the health system discovered more than half of families identifying a need didn’t accept assistance. In some cases, the most vulnerable patient populations were resistant to answering the screening questions at all. To address these concerns, Nemours Children’s refined its provider toolkit to include explanations outlining the importance and methodology behind the screening, as well as uniform language to share with patient families.
Thornton and her team are still gathering data to quantify the new screening process’ impact on health outcomes, but early anecdotal feedback indicates that providers are open to screening more regularly with the streamlined tool and protocols in place. Ultimately, Nemours plans to use the data to bolster tangible resources within the clinics where patients and families more frequently screen for immediate needs.
“We want to empower clinicians to respond to those needs in real time,” Thornton said. “There’s a lot more work to do, but we’re hopeful the screening can improve the long-term health and well-being of children by addressing the early onset of chronic diseases or avoidable utilization of health care.”
