DULCE: An Evidence-based Intervention to Tackle SDOH in Pediatrics

Root Cause Coalition 2nd Annual National SummitLouisville, KY

October 10, 2017

Breakout Session #3: 10:45am-12n

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution

Panelists

• Baraka Floyd, MD – Clinical Assistant Professor, Stanford Children’s Health

• Samantha Morton, JD – CEO, MLPB

• Deneisha Watson - Family Specialist, Palm Beach County, Florida

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DULCE:

Developmental Understanding and Legal Collaboration for Everyone

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Session Objectives

1. Understand common barriers facing socially high-risk families in accessing SDOH-related supports

2. Understand need for “upstream” screening of issues around SDOH

3. Understand value of evidence-based interdisciplinary team approach to screening and support for issues around SDOH

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution

Background

• First six months of infant’s life are uniquely challenging for families and highest risk timeframe for child abuse and neglect

Birth of

Infant

Physical Factors

Social Factors

Emotional Factors

Economic Factors

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What is DULCE?

• Innovative, universal pediatrics-based intervention

• Primary care sites bolster family strengths through:

– Structured coaching for parents on infant development milestones

– Proactively detecting and addressing SDOH

• Intervention includes:

• Highly structured interdisciplinary team

• Dedicated Family Specialist trained and supported by:

• Legal partnership that strengthens families’ ability to secure concrete supports

• Brazelton Touchpoints training and reflective mentorship to promote knowledge of parenting and child development and to strengthen collaborative parent, child and provider relationships

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DULCE: The Social Ecological Model

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DULCE: Grounded in Strengthening FamiliesTM

DULCE focuses on bolstering 5 protective factors:

1. PARENTAL RESILIENCE: a parent’s ability to bounce back from difficulties

2. SOCIAL CONNECTIONS: a network of informal or formal supports (e.g., friends, family, faith group)

3. CONCRETE SUPPORTS: knowing where to turn for help and how to navigate these systems (e.g., identifying and accessing programs to help with food, housing, utilities, etc.)

4. KNOWLEDGE OF PARENTING AND CHILD DEVELOPMENT: parents know what to expect as their children grow and what behaviors are appropriate for a given age

5. SOCIAL AND EMOTIONAL COMPETENCE OF CHILDREN: children learn to talk about and handle feelings

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DULCE: The Intervention

• Over the course of a child’s first 6 months of life, DULCE provides:

– information on healthy child development

– parenting support, and

– help connecting families to existing community resources available to them.

• The goal is to inform and empower families to become independent with the skills needed to advocate for themselves.

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DULCE: The Intervention

• First 4 well-child visits: screening for maternal depression and barriers to concrete supports, focus on the baby’s developing temperament and personality and related parent coaching.

• 6-month visit: wrap-up to the intervention, transition plan implementation to assure ongoing support within the family-centered medical home.

• Weekly interdisciplinary Case Review assures all positive screens are addressed on ongoing basis.

• Leveraging of legal partnerships throughout to help families overcome barriers to concrete supports (including rapid response representation)

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DULCE: The Evidence Overall

• Randomized controlled trial conducted at Boston Medical Center (Pediatrics) in 2010-12 showed:

– reduced ED utilization

– better adherence with well-child visits and immunizations, and

– improved access to concrete supports (SNAP benefits, utility service, etc.)

Robert Sege, MD, Ph.D et al. Medical-legal strategies to Improve Infant Healthcare: A Randomized Trial. Pediatrics (July 2015)

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DULCE: The Evidence re: SDOH

• Intervention families secured valuable supports for which they were eligible (food, utility service) at roughly twice the pace of control families

6 months v. 12 months

Robert Sege, MD, Ph.D et al. Medical-legal strategies to Improve Infant Healthcare: A Randomized Trial. Pediatrics (July 2015)

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DULCE: Refinement and Replication

• DULCE now being refined and scaled in 7 communities in CA, FL, and VT through national demo project led by the Center for the Study of Social Policy

• Key refinement is embedding of DULCE within county-level Early Childhood systems affiliated with EC-LINC (Early Childhood-Learning and Innovation Network for Communities)

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DULCE’s “Footprint”

• California First 5 Commissions in Alameda, Los Angeles and Orange

– Highland Pediatric Clinic

– The Children’s Clinic

– St. John’s Well-Child & Family Center

– Dr. Louis C. Frayser Health Center

– Northeast Valley Health Corp./Sun Valley

– Clínica CHOC Para Niños -Children’s Hospital of Orange County

• Children’s Services Council of Palm Beach County, Florida

– C.L. Brumback Primary Care Clinic

• Lamoille Family Center in Lamoille County, Vermont

– Appleseed Pediatrics

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DULCE in action – Palm Beach County, FL!

DULCE screening post-Hurricane Irma

Due to the recent natural disaster, many families are lacking in resources. Utilizing the DULCE screening tool and

schedule has allowed for ongoing conversations with families and assisted in identifying developing needs, such as:

• Financial Relief;

• Assistance with baby supplies;

• Clothing; and

• Support for legal problems.

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DULCE in action – Palm Beach County, FL!

When Families Screen Positive for Food Insecurity, FS is prepared!

• Importance of early screening

• Building rapport and using Touchpoints Reflective Practice and Motivational Interviewing techniques

• Holistic approach that sees the whole family

• Ongoing education in eligibility frameworks, local resources, and dynamic policies and practices at

bureaucratic level

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DULCE Success Stories – Palm Beach County, FL!

Trends in Positive Screens Generate System-Level Innovation

Upon utilizing DULCE concrete support screening with individual families, programmatically it was discovered that their transportation needs far exceeded what was currently

being offered by the clinic.

This triggered a policy and procedure change to broaden services offered to meet the identified needs of more families.

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution

Other Success Stories!

Legal Partner investigated non-enrollment of infant in benefit programs, resolution triggers

3+ months of retro benefits for family!

Family notified that baby was not enrolled in CalFresh, CalWORKs, or Medi-Cal because of lack of proof infant lives in home and is resident of Alameda County. Further, baby’s name was incorrect in SSA database, so his (temporary) medical card indicated wrong name, which could pose barrier to healthcare access.

Legal partner submitted appeal and contacted management. Baby’s name has been corrected. Baby has been added to assistance unit retroactive to spring 2017, resulting in increase in family income..

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1. Common Barriers to Concrete Supports

(a/k/a negative SDOH)

Complex systems

Complex Bureaucracies

Differing Priorities

Stigma Misinformation Fear

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2. The Imperative to Screen for Risk, not just Crisis

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Screen comprehensively, but

don’t overwhelm families

Pair screening with Know Your Rights

education for parents

Pay attention to intersections with

immigration status, IPV, and maternal

depression

FamilyFamily

Specialist

Primary Relationship

Legal Partner

Building capacity of Family Specialist to problem-solve with families; legal issue-spotting; some intake/representation of families confronting legal crises

3. Why SDOH Interventions Must be Interdisciplinary

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DULCE Bridges Pediatric Care Transformation

and the SDOH Frontier

• American Academy of Pediatrics Policy on “Poverty and Child Health” recommends that pediatricians screen for poverty and provide resources to address it.

• Bright Futures Fourth Edition has new priorities!

– Highlights parents concerns and SDOH as priorities at EVERY routine visit

– Maternal depression screening 4 times in 6 months

– Strengths based approaches

”DULCE is what I’ve always dreamed to do in my practice”

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DULCE leverages Continuous Quality Improvement (CQI)

to support practice-level changes

• DULCE interdisciplinary team participates in monthly CQI meetings

• DULCE discipline-specific participants perform Plan-Do-Study-Act cycles

• Using data to

– Improve adherence with on-time well-child visits

– Improve screening procedures

– Strengthen family engagement (e.g., contacting families before visits to assist with agenda setting)

• Observe alignment of positive screens for SDOH with family priority-setting (bandwidth) for short-term problem-solving efforts

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution

The Future!

• DULCE’s is a health care policy blueprint for high-quality care delivery and cost management in pediatrics

– Barriers uncovered allow systematic re-shaping of practice to better serve patients

– Supports implementation of Bright Futures 4 recommendations around SDOH, family strengths

– Provides low-dose, high-impact family-level intervention without outreach costs associated with home visiting programs

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution

Questions?

Prepared for Root Cause Coalition 2d Annual Summit – 10/10/17 – not for reproduction or distribution