Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial.

Importance: While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs. Objective: To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs. Design, Settings, and Participants: In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019. Interventions: Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months. Main Outcome and Measures: Child emergency department visit or hospitalization within 12 months of study enrollment. Results: Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized. Conclusions and Relevance: In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization. Trial Registration: ClinicalTrials.gov Identifier: NCT01939704.

Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial.

INTRODUCTION: Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician's counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents. MATERIALS AND METHODS: Parents of patients aged 4-18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale). RESULTS: We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10-0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months. CONCLUSION: While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02623855.