Interventions to assess social needs for children with medical complexity and their families: A scoping review

Accountable Care Organizations have encouraged pediatric practices to adopt a "medical home" model of care. While it is widely understood that social needs can impact the health and wellbeing of pediatric patients, the social needs of Children with Medical Complexity (CMC) and their families are less frequently assessed and quantified. We sought to determine how clinical programs for CMC were assessing social needs and providing effective interventions.

Two reviewers used a structured screening protocol to identify English language articles from PubMed, Google Scholar, and Elsevier that used some method of assessment in a clinical setting to determine the social needs of CMC and provide targeted resources to their families.

Five included studies describe interventions which assess CMC and their families for unmet social needs. Of these, three utilized paper/online screeners with resource referral, one implemented a community health worker program to assess needs and intervene, and one utilized Electronic Medical Record (EMR) data to inform care coordination meetings. Studies used multiple clinical roles to facilitate assessment including medical providers, nurses, social workers, and community health workers.

Existing literature describes multiple ways in which interdisciplinary teams can improve healthcare delivery to assess CMC and their families for unmet social needs. In addition, a variety of interventions have been developed to address the social needs of CMC.

Health-related social needs screening can help connect families of CMC to needed resources and address unmet needs. The research base for the CMC population is small and evaluations of these studies limit generalizable recommendations. Additional study is needed to generalize these findings and compare different modes of assessment and intervention to determine how families are best able to get their needs met.