Creating a Psychosocial Screening Tool to Drive Targeted Psychosocial Interventions in Pediatrics Alisa Collins, MSW, LMSW, LCSW; Rachel Epler, MPA
Children’s Mercy Kansas City, Kansas City, Mo. Introduction Screening for social determinants of health needs can increase the likelihood care plans and interventions will be successful after discharge (Morone, 2017). The existing psychosocial screening protocol allowed for variability between social workers and inconsistencies in patients identified as “at risk” or in need of additional intervention. Social workers were reviewing inpatient admissions for psychosocial risk factors, but we wanted to increase the reliability and standardization of the screening process, while building a data set from which to create future targeted intervention protocols. We developed and implemented an admission screening tool which incorporated the five domains of social determinants of health as outlined by Healthy People 2020 (HHS, 2018), enabling standardization of the process and consistency in the determination of need for intervention.
Objectives Develop and implement updated psychosocial screening process and documentation tool to: Standardize screening process Improve reliability of screening process Decrease social worker time required to screen Demonstrate need for social work interventions to enable staffing and resource optimization Increase data collection capabilities to drive development of future intervention protocols
Summary Previous process: Screening was completed with use of “High Risk Screening Tool” protocol which outlined chart review for potential risk factors including previous criteria (right). Previous result: Results varied by social worker and documentation was entered in chart as free-text note. No standardized positive or negative result documented; documentation of reasons for follow-up to individual discretion.
Methods A representative group of social workers collaborated to create the new screening tool. Each representative had the opportunity to offer feedback on what risk factors were commonly identified in their areas to best capture patient needs, in addition to those found in our literature review. Before final implementation, representatives participated in a pilot project with use of the screening tool. This process included tracking time for the new screening process to compare to previous screening times and noting any issues that arose. The screening form was then updated based on pilot participant feedback for department-wide education. Members of the pilot project remained available for team member support throughout implementation. Clarification of the purpose of screening was also part of the process. Screening is a quick review of patients’ charts and ideally takes no more than a few minutes per patient. Every patient chart is screened for psychosocial risk factors upon admission and intervention is planned accordingly. ‘Screening’ is sometimes used interchangeably with or confused with ‘psychosocial assessment.’ A psychosocial assessment involves a thorough review of various psychosocial domains either through caregiver interviews or caregiver selfreport. In an acute setting, social work intervention may include a complete psychosocial assessment, but this would typically be determined as part of the intervention dictated by the screening results. Previous criteria: Any DME needs, Barriers to accessing healthcare, Child Protection Services, Concerns reported about end of life issues, Crisis/ accident or trauma, Ingestion, Lack of resources, New (life altering) diagnosis, Readmission for social reasons, Suspected abuse or neglect, IHELP (Income/Insurance/IPV, Hunger/Housing, Education/Ensuring safety, Legal/ Law Enforcement, Power of Attorney/ Guardianship/ Consent)
Summary, Cont. New process: Care coordination risk factors are divided into two categories. If a chart is positive for a category 1 risk factor, further intervention is indicated. Category 2 risk factors may result in a positive or negative screen, pending clinical judgment.
New criteria: Category 1:
Category 2:
New result: Updated documentation is streamlined into check-boxes, significantly reducing time spent charting. Uniform documentation supports data-gathering to show highest psychosocial needs.
Results An updated admission screening tool was implemented in across inpatient social work settings in July 2018. The updated screening process incorporated elements of the five domains of social determinants of health as outlined by Healthy People 2020 (HHS, 2018): economic stability, education, social/community context, health and health care access, and neighborhood/built environment. The previous protocol was in narrative format and contained no standardized framework or location for results. The updated version contained checkbox for ease of data collection, clearly defined standards for chart review and positive screen determination, Figure 1. standardized results and follow-up procedures. Despite the additional criteria, average time for social workers to complete a screening decreased by 48% (see figures 1 and 2). Post-implementation data collection demonstrated need for social work intervention in 56% of inpatient admissions.
Outcomes 48% decrease in social worker time to complete screening. Target: 25%
Figure 2. Measure Average Time to Complete Screening in Minutes
Baseline
Pilot
3:18
1:36
91% appropriate social work follow-up within 24 hours of screening. Target 90% Screening Results (8/1/18-12/31/18) Total screenings performed Screen positive Social worker to provide appropriate intervention. No intervention planned due to caregiver wishes. No intervention planned due to existing connection. Screen negative Positive screens with follow-up documentation within 24 hours.
#
%
8335 4656 4268 8 405 3706 3897
-55.86% 51.21% 0.10% 4.86% 44.46% 91.30%
Figure 3. A breakdown of screening results and follow-up documentation.
Implications A reliable and efficient psychosocial screening tool is an essential resource to the inpatient social work workflow. A reliable screening tool ensures patient needs are identified and met and facilitates team care coordination across the spectrum of care. In the acute care setting, social workers often do not have the opportunity to work with families long term to provide the ongoing intervention and support needed to assist families in ongoing care management. By creating a standardized documentation criteria and chart location, team members can easily view patient needs and follow-up, and coordinate with team members in the ambulatory and community settings to provide ongoing intervention. The data collection mechanisms created by the new tool is the basis for essential quality and process improvement work now in process such as creation of standard work around intervention and follow-up protocols, updates to documentation templates and workflow to provide additional resources and accountability to ensure all identified needs are met, and to assist leaders in proactive staffing optimization and resource allocation.
References Lax, Y., Martinez, M., & Brown, N. M. (2017). Social Determinants of Health and Hospital Readmission. Pediatrics,140(5). doi:10.1542/peds.2017-1427 Morone, J. (2017). An Integrative Review of Social Determinants of Health Assessment and Screening Tools Used in Pediatrics. Journal of Pediatric Nursing, 37, 146. doi:10.1016/j.pedn.2017.08.059 Sills, M. R., Hall, M., Colvin, J. D., Macy, M. L., Cutler, G. J., Bettenhausen, J. L., . . . Shah, S. S. (2016). Association of Social Determinants With Children’s Hospitals’ Preventable Readmissions Performance. JAMA Pediatrics, 170(4), 350. doi:10.1001/jamapediatrics.2015.4440 US Department of Health and Human Services (HHS) (2018). Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States. (2010, July 26). Retrieved from https://www.healthypeople.gov/2020/topicsobjectives/topic/social-determinants-of-health, Accessed 05 October, 2018.
Contact Info Alisa Collins, MSW, LMSW, LCSW Masters Social Worker Email: abcollins@cmh.edu Phone: 816-983-6687
Rachel Epler, MPA Care Continuum Manager, Strategy and Analytics Email: rrepler@cmh.edu Phone: 816-302-0395