"We Don't Want to Screen for the Sake of Screening": A Qualitative Evaluation of a Social Needs Screening and Referral Intervention in the NICU.

BACKGROUND: Low uptake of social determinants of health (SDH) screening and referral interventions within neonatal intensive care units (NICUs) is partly due to limited understanding of the best procedures to integrate this practice into routine clinical workflows. PURPOSE: To examine the feasibility and acceptability of an SDH screening and referral intervention in the NICU from the perspective of neonatal nurses; and to identify factors affecting implementation outcomes. METHODS: We conducted 25 semistructured interviews with NICU nurses. We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to guide interview questions and codebook development for directed content analysis. Themes were mapped onto the 3 PARiHS domains of context, evidence, and facilitation. FINDINGS: Analysis yielded 8 themes. Context: Nurses felt that stressors experienced by NICU families are magnified in a safety net environment. Nurses shared varying viewpoints of the roles and responsibilities for social care in the NICU, and feared that scarcity of community resources would make it difficult to address families' needs. Evidence: The intervention was perceived to increase identification of adverse SDH and provision of resources; and to potentially jump-start better caregiver and infant health trajectories. Facilitation: Procedures that improved acceptability included dynamic training and champion support, regular feedback on intervention outcomes, and strategies to reduce stigma and bias. CONCLUSION: We identified contextual factors, concrete messaging, and training procedures that may inform implementation of SDH screening and referral in NICU settings.

Patient Perspectives of the Hospital Discharge Process: A Qualitative Study.

Care transitions after hospitalization require communication across care teams, patients, and caregivers. As part of a quality improvement initiative, we conducted qualitative interviews with a diverse group of 53 patients who were recently discharged from a hospitalization within a safety net hospital to explore how patient preferences were included in the hospital discharge process and differences in the hospital discharge experience by race/ethnicity. Four themes emerged from participants regarding desired characteristics of interactions with the discharge team: (1) to feel heard, (2) inclusion in decision-making, (3) to be adequately prepared to care for themselves at home through bedside teaching, (4) and to have a clear and updated discharge timeline. Additionally, participants identified patient-level factors the discharge planning team should consider, including the social context, family involvement, health literacy, and linguistic barriers. Lastly, participants identified provider characteristics, such as a caring and empathetic bedside manner, that they found valuable in the discharge process. Our findings highlight the need for shared decision-making in the discharge planning process to improve both patient safety and satisfaction.

Implementing Social Risk Screening and Referral to Resources in the NICU.

OBJECTIVE: Social risk screening is recommended by the American Academy of Pediatrics, but this practice is underutilized in NICUs. To address this gap in social care, we aimed to increase rates of: (1) systematic social risk screening and (2) connection with community resources, each to ≥50% over a 14-month period. METHODS: We conducted a quality improvement initiative from November 2020 to January 2022. We adapted a screening tool and used Plan-Do-Study-Act cycles to integrate screening and referral to resources into clinical workflow. Primary outcome measures included the percentage of (1) families screened and (2) connection with resources. We examined screening by maternal race/ethnicity and primary language. Process measures were (1) time from admission to screening and (2) percentage of referrals provided to families reporting unmet needs and requesting assistance. We used statistical process control to assess change over time and χ2 tests to compare screening by race/ethnicity and language. RESULTS: The rates of systematic screening increased from 0% to 49%. Among 103 families screened, 84% had ≥1, and 64% had ≥2 unmet needs, with a total of 221 needs reported. Education, employment, transportation, and food were the most common needs. Screening rates did not vary by race/ethnicity or language. Among families requesting assistance, 98% received referrals. The iterative improvement of a written resource guide and community partnerships led to increased rates of connection with resources from 21% to 52%. CONCLUSION: Leveraging existing staff, our social risk screening and referral intervention built the capacity to address the high burden of unmet needs among NICU families.

Association of Primary Language with Provision of Mother's Milk Among Very-Low-Birthweight Infants in Massachusetts.

Background: Racial/ethnic inequities in mother's milk provision for hospitalized preterm infants persist. The extent to which primary language contributes to these racial/ethnic inequities is unknown. Objective: Examine associations of maternal race/ethnicity and primary language with (1) any/exclusive mother's milk at hospital discharge and (2) the time to cessation of mother's milk provision during the hospitalization. Methods: We examined 652 mother/very-low-birthweight (VLBW) infant dyads at 9 level 3 neonatal intensive care units in Massachusetts from January 2017 to December 2018. We abstracted maternal race/ethnicity and language from medical records, and examined English and non-English-speaking non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic mothers of any race. We examined associations of race/ethnicity and language with (1) any/exclusive mother's milk at discharge (yes/no) using mixed-effects logistic regression and (2) cessation of mother's milk during the hospitalization using cox proportional hazard models, adjusting for gestational age, birthweight, and accounting for clustering by plurality and hospital. Results: Fifty-three percent were English-speaking NHW, 22% English-speaking NHB, 4% non-English-speaking NHB, 14% English-speaking Hispanic, and 7% non-English-speaking Hispanic. Compared with English-speaking NHW, NHB mothers (English adjusted odds ratio [aOR] 0.28 [0.17, 0.44]; and non-English-speaking aOR 0.55 [0.19, 0.98]), and non-English-speaking Hispanic mothers (aOR 0.29 [0.21, 0.87]) had lower odds of any mother's milk at discharge. In time-to-event analyses, non-English-speaking Hispanic (adjusted hazard ratio [aHR] 4.37 [2.20, 6.02]) and English-speaking NHB mothers (aHR 3.91 [1.41, 7.61] had the earliest cessation of mother's milk provision. Conclusion: In Massachusetts, maternal primary language was associated with inequities in mother's milk provision for VLBW infants with a differential effect for NHB and Hispanic mothers.

Beyond income: material hardship and the health and healthcare of premature children.

OBJECTIVES: To estimate national prevalence of household hardships (food insufficiency, financial hardship, and difficulty paying medical bills) among children born term and preterm; and examine associations of household hardships with preterm children's outcomes (health status, emergency room visits, and unmet healthcare needs). METHODS: We studied 24,026 children aged 0-3 years born term, preterm with moderately low birth weight (1501-2499 grams) and preterm with very low birth weight (VLBW; ≤1500 grams). Using propensity score matching to control for correlates of poverty, we examined associations of hardships and child outcomes. RESULTS: Compared with term, households with preterm VLBW children had >2-fold higher odds of financial hardship (aOR:2.63; 95% CI: 1.26-5.46) and >5-fold higher odds of difficulty paying bills (aOR:5.60; 95% CI: 2.35-10.35). Matching for sociodemographics, special healthcare needs, income and receipt of public benefits, hardships were independently associated with adverse preterm children's outcomes. CONCLUSIONS: Addressing household hardships is needed to optimize preterm child outcomes.

National Prevalence of Social Determinants of Health Screening Among US Neonatal Care Units.

OBJECTIVES: The extent that universal social determinants of health (SDH) screening in clinical encounters, as recommended by the American Academy of Pediatrics, has been implemented in inpatient pediatric settings is unknown. We aimed to determine the national prevalence and predictors of standardized SDH screening in US level 2 to 4 neonatal care units (NICUs), describe characteristics of SDH screening programs, and ascertain beliefs of clinical leaders about this practice in the NICU setting. METHODS: We randomly selected 100 hospitals with level 2 to 4 NICUs among each of 5 US regions (n = 500) and surveyed clinical leaders from January to November 2021 regarding standardized SDH screening. Responses were weighted for number of level 2 to 4 NICUs in each region and nonresponse. RESULTS: Overall response rate was 34% (28%-40% by region). Twenty-three percent of US level 2 to 4 NICUs reported standardized SDH screening. We found no associations of hospital characteristics, such as region, size, or safety-net status, with implementation of this practice. Existing programs conducted systematic screening early in the hospitalization (84%), primarily led by social workers (92%). We identified practice variation regarding the type of screening tool, but there was substantial overlap among domains incorporated in the screening. Reported barriers to implementation included perceived lack of resources, inadequate referrals, and lack of an inpatient screening tool. CONCLUSIONS: The prolonged neonatal hospitalization provides opportunities to systematically address SDH. Yet, only 23% of US level 2 to 4 NICUs have implemented this practice. To scale-up implementation, quality improvement may support adaptation of screening and referral processes to the NICU context.

Maternal language disparities in neonatal intensive care unit outcomes.

OBJECTIVE: To examine associations of maternal primary language with neonatal intensive care unit (NICU) outcomes (mother's milk at discharge, necrotizing enterocolitis [NEC], late-onset sepsis, weight gain) DESIGN: We performed a retrospective cohort study of mother-infant dyads (<34 weeks' gestation) in 9 NICUs (1/2016-12/2019), examining associations of maternal language (English [ref], Spanish, Other) with NICU outcomes, adjusting for birth weight for gestational age z-score, race/ethnicity, maternal age, and clustering by hospital. RESULTS: Among 1402 mothers, 85% spoke English, 7% spoke Spanish, and 7% spoke another language. Compared to English, infants with Spanish-speaking mothers had slower growth (-0.34 z-score units [-0.58, -0.10]). Infants with other non-English-speaking mothers had increased mother's milk at discharge (aOR 1.48 [1.18, 1.85]), NEC (aOR 1.43 [1.05, 1.95]), late-onset sepsis (aOR 2.84) [1.67, 4.83] and slower growth (-0.17 z-score units [-0.29, -0.05]). CONCLUSIONS: After adjustments, preterm infants with non-English-speaking mothers had worse outcomes than infants with English-speaking mothers.

Linguistic Disparities in Child Health and Presence of a Medical Home Among United States Latino Children.

OBJECTIVE: The impact of household language on Latino-White and Latino intragroup disparities in child health and having a medical home in the United States is poorly understood. This study aimed to examine these disparities 1) between Whites and Latinos (overall and stratified by English-primary-language [EPL] and non-English-primary-language [NEPL] households); 2) within Latinos, stratified by household language; and 3) potential moderation of disparities by social determinants. METHODS: Cross-sectional analysis of nationally representative sample of children 0 to 17 years old from the 2016-2018 National Survey of Children's Health. We evaluated associations of child race/ethnicity and household language with child health and presence of a medical home. Multivariable logistic regression was used to compare groups of interest, adjusting for sociodemographic factors and health needs. Moderation was assessed using interaction terms for household income, parental educational attainment, and child insurance coverage. RESULTS: Among 81,514 children, 13.5% were NEPL Latino, and 19.4% were EPL Latino. Compared with EPL Whites, both EPL and NEPL Latinos had reduced odds of excellent/very good health (adjusted odds ratio [aOR]: 0.70; 95% confidence interval [CI]: 0.58-0.84; and aOR: 0.42; 95% CI: 0.33-0.53) and presence of a medical home (aOR: 0.62; 95% CI: 0.56-0.69; and aOR: 0.45; 95% CI: 0.37-0.54), respectively. Among Latinos, NEPL (vs EPL) was also associated with reduced odds of excellent/very good health (aOR: 0.61; 95% CI: 0.46-0.83), and presence of a medical home (aOR: 0.66; 95% CI: 0.48-0.78); these associations were magnified by adverse social determinants. CONCLUSIONS: Striking Latino-White and within-Latino medical-home disparities persist in the United States, particularly for NEPL Latino children. Interventions should target social determinants and the rich sociocultural and linguistic diversity of the Latino population.