Should Social Determinants of Health Interventions in Primary Care Use Universal or Targeted Approach? Lessons from an Observational Cohort Study of a Universal Pediatric Primary Care Approach

Principal Investigator: MaryCatherine Arbour, MD, MPH

Authors: Placidina Fico, MPH, Robert Sege, MD, PhD, Sidney Atwood, BA, MaryCatherine Arbour, MD, MPH
Lay Abstract

Increasingly, healthcare systems aim to address patients’ health-related social needs(HRSN)–responsible for approximately 60% of health outcomes–through routine healthcare; questions remain about the most effective ways to do so. Targeted approaches limit services to patients meeting specific eligibility criteria; universal approaches offer services to all patients, with varied intensity (i.e., “tailoring). This observational cohort study explored the benefits of universal versus targeted interventions by comparing two cohorts of DULCE families with infants born January 2017 through December 2019. We defined cohorts based on observable family characteristics commonly used ineligibility criteria in targeted programs serving families with infants. We analyzed outcomes related to program participation, healthcare utilization, prevalence of HRSN and connection to supports in the Risk Criteria Absent (“RCA,” n=862) and Risk Criteria Present (“RCP,” n=815) cohorts. All families offered DULCE enrolled. There were no differences in healthcare utilization outcomes. Over half of RCA families screened positive for at least one HRSN. Results suggest that, prior to DULCE, RCA families were not using HRSN supports they were eligible for. This universal approach led to high uptake among all families and challenges the assumption that risk-based eligibility used in targeting can effectively identify and reach families needing support.

Scientific Abstract

Increasingly, healthcare systems aim to address patients’ health-related social needs(HRSN)–responsible for approximately 60% of health outcomes–through routine healthcare; questions remain about the most effective ways to do so. Targeted approaches limit services to patients meeting specific eligibility criteria; universal approaches offer services to all patients, with varied intensity (i.e., “tailoring). This observational cohort study explored the benefits of universal versus targeted interventions by comparing two cohorts of DULCE families with infants born January 2017 through December 2019. We defined cohorts based on observable family characteristics commonly used ineligibility criteria in targeted programs serving families with infants. We analyzed outcomes related to program participation, healthcare utilization, prevalence of HRSN and connection to supports in the Risk Criteria Absent (“RCA,” n=862) and Risk Criteria Present (“RCP,” n=815) cohorts. All families offered DULCE enrolled. There were no differences in healthcare utilization outcomes. Over half of RCA families screened positive for at least one HRSN. Results suggest that, prior to DULCE, RCA families were not using HRSN supports they were eligible for. This universal approach led to high uptake among all families and challenges the assumption that risk-based eligibility used in targeting can effectively identify and reach families needing support.

Clinical Implications
A universal approach to address health-related social needs in pediatric clinics identified a significant number of families with unmet HRSN. Many were eligible for but not accessing targeted interventions. In practice, stigma and/or logistical complexity may offset targeting’s theoretical efficiencies.

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