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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Referrals.

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Strategy. Screening for Community Factors of Health

Approach. Empower caregivers with tools to assess unmet social needs and connect patients with necessary care providers in medical networks and community based health services

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Overview. SDOH screening can lead to collaborative care interventions across most subgroups, adolescents aged 12-17, despite proportionate screening and referral process.[1] An algorithm was integrated into the EHR to prompt eligible patients for depression screening, streamlining the screening process.[1] Additionally, a care manager reached out to eligible patients within 7 days to discuss symptoms and treatment options, providing examples of brief cognitive behavioral therapy. (CBT) or community referrals, and offering case management during treatment.[1]

Evidence. Emerging Evidence. Strategies based on emerging evidence show promise but have not undergone extensive testing. While these approaches demonstrate potential, their effectiveness remains unconfirmed. Prioritize rigorous monitoring to ensure they achieve desired outcomes for all MCH populations.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Caregiver self-efficacy and competency surveys
  • Social needs screening tool and referral data
  • Qualitative data from caregiver interviews

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Community Health Factors.
  • Health Care Access for All MCH Populations.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Screening (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of caregivers, including healthcare providers, social workers, and community health workers, who receive training and tools to conduct SDOH screening and referrals. (Measures workforce capacity-building for SDOH screening)
  • Number of patients screened for SDOH needs and risks using standardized assessment tools and protocols. (Assesses reach and volume of SDOH screening efforts)

Quadrant 2:
Measuring Quality of Effort (“How well did we do it?”)

  • Percent of caregivers, including healthcare providers, social workers, and community health workers, who receive training and tools to conduct SDOH screening and referrals. (Measures workforce capacity-building for SDOH screening)
  • Percent of patients screened for SDOH needs and risks using standardized assessment tools and protocols. (Assesses reach and volume of SDOH screening efforts)

Quadrant 3:
Measuring Quantity of Effect (“Is anyone better off?”)

  • Number of multi-sector partnerships formed to implement community-wide SDOH screening systems who report high levels of engagement. (Measures collaborative infrastructure for SDOH screening)
  • Number of policies established to support integration of SDOH screening into healthcare delivery that results in seamless integration in workplace protocols. (Assesses enabling conditions for SDOH screening sustainability)
  • Number of communities demonstrating reductions in SDOH-related differences through systematic screening. (Measures population health impact of SDOH screening)
  • Number of multi-sector initiatives catalyzed by insights from SDOH screening programs. (Shows systems change impact of SDOH screening efforts)

Quadrant 4:
Measuring Quality of Effect (“How are they better off?”)

  • Percent of SDOH screening initiatives designed with input from communities. (Measures community engagement in SDOH screening efforts)
  • Percent of SDOH screening resources allocated to building capacity in communities facing challenges to healthcare. (Assesses focus of SDOH screening investments)
  • Percent reduction in SDOH-related differences experienced by communities through screening interventions. (Measures progress toward positive health outcomes through SDOH screening)
  • Percent of patients from various backgrounds reporting that SDOH screening affirmed their dignity and strengths. (Assesses experience of support in SDOH screening)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] Thompson, H., Faig, W., Gupta, N., Lahey, R., Golden, R., Pollack, M., & Karnik, N. (2019). Collaborative Care for Depression of Adults and Adolescents: Measuring the Effectiveness of Screening and Treatment Uptake. Psychiatric services (Washington, D.C.), 70(7), 604–607. https://doi.org/10.1176/appi.ps.201800257

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.