Melanie Cole, MS (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Melanie Cole. And today, we're discussing the clinical impacts of social determinants of health. We're joined by Dr. Stormee Williams. She's the Senior VP and Chief Health Equity Officer at Children's Health.

Dr. Williams, thank you so much for joining us today. Since implementing SDOH screening, more than half of patients have screened positive for at least one unmet social need. What surprised you the most about these findings? And what do they tell us about the patients and families that we serve?

Stormee Williams, MD: Thank you so much for having me today. I think what has surprised me the most is that when we started this screening, we really didn't know what to expect. But as we screen more and more families, number one result that we've seen and number one need that we've seen is the need for social connectedness.

We screen across six different domains, which include food insecurity, housing needs, financial insecurity, transportation needs. And social support is the number one need that continues to arise for all of our families, followed by food insecurity and financial insecurity. But that social connectedness is the thing that continues to pop up. And in this era of, you know, social media, everyone is constantly connected, we are also disconnected as a society. I think that's the thing that's so surprising, yet it's not surprising, right? As we also see the rise in depression and anxiety, we know that these things are also impacting our need for social connectedness.

Melanie Cole, MS: Well, you're certainly right, and we're seeing that more and more among our youth and our teens and tweens, that depression, anxiety disorders are certainly on the rise. And when we think of connecting, as you just said, those social needs, to our outcomes, physicians often focus, I mean, as they have done for decades, on diagnosing and treating medical conditions. But when you speak of those social determinants of health, Dr. Williams, how do those factors like food insecurity, financial stress, limited social support, which we know is happening, how do those influence a patient's treatment plan? How should they influence a patient's treatment plan, recovery, and long-term health outcomes?

Stormee Williams, MD: Yes. So, we as physicians cannot merely focus on just the medical care that we provide, although it's very important. When you look at overall health outcomes, we know that only 20% of health outcomes are tied to healthcare access and quality of care. The other 80% are related to behaviors, and then that 50% are actually tied to socioeconomic status and those behaviors. And 50% is actually tied to ZIP code and where someone lives and those social drivers of health. And so if we look at those things like financial insecurity, food insecurity, or access to quality food and housing, those things have more of an impact on one's health than, like I said, what prescriptions we write or what treatment plan we provide for. So, ignoring those things have a huge impact on the time that they're at home.

I recently read about the 15 minutes that we as providers have with our patients when we're in the room with them, and think about all the other minutes that they are outside of our care. So, what's going to have more of an impact on the other 15 minutes that we'll get with them when they come back? it's actually those other minutes, right, outside of our care, so we can't ignore those minutes. And that's what social drivers of health or social determinants of health is really getting at. It's just considering those other determinants of health. So, we know that we can't solve those things. We can't solve the economy. We can't solve for housing insecurity and food insecurity, but just being aware that those things have an impact on health makes us better clinicians and better physicians. And just asking our families if they have any concerns with those things, and although we can't solve them, we can help connect them to those resources so that they can actually take away some of those burdens, or at least know that there are some resources out there that we can help them connect to.

Melanie Cole, MS: Dr. Williams, we've known for a while that culturally diverse, underserved populations have a lack of access to care, but also when we think of the psychosocial and behavioral health, somewhat of a mistrust besides that lack of access. So from a behavioral health standpoint, what are some of the most common emotional psychological challenges that you have seen when you know that patients are experiencing housing instability, food insecurity, financial hardship? How do these challenges affect engagement with care, access to healthcare, and engagement with the healthcare professionals themselves?

Stormee Williams, MD: Yeah, you're referring to that trauma-informed care and the fact that families are bringing with them that trauma of their everyday lives, of their past experience, sometimes with the medical community, but oftentimes just their lives and their backgrounds. Shoot, if you just listen to the news, sometimes that's just trauma, right?

And if we just take a minute to consider that when we approach each patient and just be empathetic to what they may or may not have experienced and just consider that. So, taking that pause and considering the fact that sometimes people may have had negative experiences when interacting with healthcare, but then also realizing that they may have burdens on them that are impacting their health allows us to interact with them in more—just aware in manners. And I say that, it's a very broad way of saying trauma-informed care. And what do I mean by that? Sometimes we use terms in different settings to make us seem, kind of callous to what families are experiencing.

I'll give you an example. I think about my time in the emergency room during training. And oftentimes we use words like, these are frequent flyers for using the emergency room, kind of like primary care, where they could use a lower level of care, or they're non-compliant with our treatment plan.

But sometimes if we take a step back and say, "Why might they be non-compliant with our treatment plan?" Or "Why do they continue to show up in the emergency room?" Maybe it's a lack of transportation, or maybe it's the fact that the parents might be working a double shift and the only care that's available after 8:00 PM is the emergency room for them to seek care for those things.

If we just take a pause and think about why are they seeking care in this manner or why do they seem agitated when they're coming here, maybe it's because they are experiencing some situations that are causing some stress in their lives. So, they might seem more stressed out or frustrated. It may have nothing to do with us. It may have something to do with an experience they had with the last healthcare provider that they dealt with. We don't know, and it may have nothing to do with us. But if we can just be a little bit more sensitive and aware that oftentimes people bring with them backgrounds and histories and experiences that impact the way they interact with the healthcare environment, we can't take it personally, but we can do our best to just pause, again, to just do our best to interact with them today to get them the best care that we can provide in that moment.

Melanie Cole, MS: So, expanding on that for just a minute, and thank you for telling us how trauma-informed, culturally competent care really looks like in practice. But I'd like you to speak about how we can improve that trust to improve those health outcomes. What would you like other providers to know and take forward to their patients about that outreach, that understanding, as you say, that patience? Because I think that's one of the most important aspects that you just mentioned, was that patience with your patients, but also with their families, so that they can really trust their healthcare provider so that they will be forthcoming with information which is so important to their care.

Stormee Williams, MD: Yes, it's so important. And sometimes, again, we are in situations that can be high-stress ourselves, right? We have so many patients to care for, and oftentimes we ourselves are in very traumatic situations depending on the work environment that we're in. But doing little things like sitting down and being on eye level with our patients, asking before we examine them or before we touch them, asking, "Is it okay if I listen to your heart right now?" Or saying, "May I examine your child right now?" Little things like that really goes a long way to show respect and to just show that we are being respectful and aware that we are about to examine them. And it also gives the patient a sense of agency over their body, and that is just a piece of trauma-informed care.

And what trauma-informed care is just saying that we realize that you are bringing with you a history, and we're trying to respect that as much as possible. So, those little things just go a really long way when it comes to taking care of patients. And reading the room, right? When you notice that someone is stressed, oftentimes we can get defensive. Our guard kind of goes up, but doing our best to deescalate a situation and realizing that we have a lot of experience in these situations, and we have a lot of ability to just kind of temper situations. And sometimes it can be hard. But in just respecting our patients' backgrounds and what they bring with them can go such a long way in helping us to provide that care for our patients and their families.

And also, recognizing that our way isn't always the best way. There have been times when, just for me as a pediatrician, allowing a child to hold the hand of their older sibling allowed me to look inside their ear or to hold onto their favorite stuffy, allowed me to get a good belly exam if I needed to. Just doing little things like that. Did that stuffy get in the way? Sometimes. But it also helped me to get a better exam. So, things that may not be what I read in a book or how I learned how to do it, but if it helped me to get a good exam, allowed me to get a good history from the family or to just quiet the room. Those are the things that allow us to be really good physicians and allow us to do our work as best as we can.

Melanie Cole, MS: right? Those are not things, as you say, that you might have learned in school. So, these are things that come with patience, experience, compassion, knowledge to, as you say, read the room. And another important aspect, I feel, Dr. Williams, about reading the rooms is supporting the caregivers. We know that hospitalizations and hospitals indeed are scary places. They can be overwhelming for the patient, but also for their caregivers, especially if there is a language disparity going on. There are so many avenues by which this can be a little bit traumatic and scary. How does limited social support affect those families emotionally, practically? Speak about the caregivers and what healthcare teams can do to better support the families as a whole.

Stormee Williams, MD: that we see, of course, a lot in pediatrics. And I'll even speak for myself. I have three children, and all three of my kids have needed the medical system. We have been patients and consumers of the healthcare system. And my husband and I have had to split our care with one had to be in the hospital with our child, the other had to be at home with the kids, with our other children. And so, oftentimes, that left us alone in the room with the patient, right? And so, did we always feel like one of us could, you know, go downstairs to get something to eat? You know, it can be very isolating.

And in general, when your child has a medically complex condition, you feel isolated as it is. Also, I'm not from Texas, so my family of origin is out of state, which a lot of us are in medical training. We travel for our training and for education. And so, it keeps us feeling isolated if we don't have that "village" around. And so, what we can do as caregivers is to speak to that. I mean, we can ask about it. And we're so fortunate at Children's Health to do this screening for social determinants of health. So, it's right there in the electronic health record where we can just look and see what our families have said that their needs are.

And one of the things we did, which we're so fortunate to have a spiritual support team that includes our chaplains, they noticed that our social support was the highest need. And they said, "Well, what can we do? This is part of what we do." And they go and just ask the families if there's something that they can do. And just because it is our spiritual support team, they don't offer any specific spiritual guidance or religious type of guidance. They just ask if there's anything that they'd like to talk about.

And we were really surprised that families really enjoy speaking to a member of our spiritual support team. And they talk about all types of things, about being away from family or being new to the area and not really having found a spiritual community here in the area, or asking for things like, you know, do we have information on childcare groups for their other children?

So just again, being aware of those types of situations and also just having another adult to talk to. Again, as pediatrician or, you know, having pediatric patients and being the only adult in the room, it gets lonely. So, having support groups for patients and patient families is really important. Having a peer group, especially disease-specific peer groups can be really important.

We were just talking with our obesity prevention and nutrition support team, and they have a support group for teenagers. And they were saying that after their first meeting, some of the teens voiced how important it was for them to be in a group of their peers, people who looked like them, and not being worried about being teased and how important that was.

So, peer support and just that social support is just so very vital. So, it doesn't seem like it's necessarily health related, but it can certainly improve health outcomes just from having that support.

Melanie Cole, MS: That's so important what you just said. And I'd like you to offer some practical guidelines for physicians. Dr. Williams, we know with the advent of electronic medical records and the need, the quotas, all the things that go on in the healthcare world right now, many physicians recognize these challenges that you're discussing here today, but they also feel, as you said, you were talking about the 15 minutes, that they have limited time and resources during a patient encounter. What are some practical ways that clinicians can really identify those social needs and connect with families with appropriate support without significantly adding to their workload? Because we know that that's just going to back up the system even more.

Stormee Williams, MD: Yes, absolutely. And listen, I have been there, and we know that no one really wants to add any administrative burden to any of our clinical staff, because throughput is important, right? Getting patients in the door and out. But we know these needs are there, and we also know that these social needs actually increase length of stay. They increase patients going to the emergency room for non-emergent issues. So, it's really important that we pay attention to them. But there are so many quick screeners out there, just like there are for behavioral health and mental health. There are really quick screeners out there. Like I said, we have them on our electronic health record, but there are just as quick resources out there.

We have something called community.childrens.com that's on our website, where families can put in their own ZIP code and find resources right in their own community. So, having just a list of very basic community-based organizations for food, housing, economic resources that families can find right in their local community, having a list right in their waiting rooms is something that physicians can do that they don't have to necessarily offer for every visit. But having it in their waiting room on a QR code, for example, that families can scan quickly and get their own resources, that's something that's very quick that doesn't add to your staff. You can put it up in the waiting room or have it on a poster, for example. But those are the things that we can do where families can kind of self-select.

It's not getting easier for families to sign up for things like, you know, WIC or SNAP benefits or anything like that, but the needs are growing. And so, we're going to continue to see these health-related social needs grow. And I tell you, we really need to help to make sure that our families know how to get these resources.

So again, finding those basic community-based organizations that are out there. Here in Texas, we have a phone number, 211, that families can also call to get resources. So just knowing what those kind of basic needs are, those are the things that I think that every physician, especially in primary care, that we should know about, so that we can direct families to those areas, and making sure your front desk staff know as well.

Melanie Cole, MS: That's a great point that you just made. And as we look ahead, Dr. Williams, healthcare continues to integrate behavioral health and social care into clinical practice. What opportunities do you see for improving outcomes and advancing that health equity? What message would you like to leave other physicians with about the role that they can play in addressing these social determinants of health to really achieve those better outcomes?

Stormee Williams, MD: Really, the role that physicians play is in advocacy. It goes beyond the exam room and the four walls of the hospital and the exam room. We have to advocate for this aspect of healthcare. It's not just on community-based organizations and nonprofits. We know that this work really does impact health. And the more that we use our voices collectively, the more it can be improved. And also to make sure that this time that we spend doing this work gets reimbursed, just like with mental health. We need to use our collective voice to advocate for reimbursement for these types of issues, using ICD-10 codes to code for the time that we are spending on these things so that we can get more social workers and behavioral health providers and mental health providers to be able to really help these families as they struggle with these things. Because I don't believe that physicians should continue to be in the place of behavioral health providers. We need those providers in place for those things, but they also need to be reimbursed for the care that they provide.

So, I think that, again, just using our collective voice, but also meeting our patients where they are and providing those resources or information on the resources that are available, that's where we can start.

Melanie Cole, MS: Before we wrap, Dr. Williams, this has been such a fascinating look into the inner workings when we're talking about those social determinants of health. Is there anything else you'd like to share?

Stormee Williams, MD: You know, I just want to encourage physicians. This is such an interesting time in our society, and it is burdensome for everyone, and I know for physicians, and pediatricians i in particular too, it can seem really hard. And not just pediatricians, but for all of us in healthcare. It can seem really hard where influencers seem to have more of a say so sometimes as opposed to real science.

So, I just want to encourage us to keep up the good fight, to continue to be motivated by the reasons we went into this work, to continue to heal, and to keep that patient in front of our mind and to keep our own personal missions in front of our minds as we do this work to keep up the good fight and to just do our small part every day.

At Children's, our mission is to make life better for kids, and I actually say that to myself every day because it gets hard. But if I do my part to make life better for kids, then I know that I'm doing something good, even if it's for one kid that day. I just keep that going in the back of my mind. So, I just want to encourage all of us to do our small part every day. And if we do that, it gets a little bit easier.

Melanie Cole, MS: Thank you so much, Dr. Williams. That was beautifully said, and I can really hear that passion in your voice. So, thank you again for all the great work that you're doing, and you can learn more at childrens.com. Thank you so much for your time with us today, and to our audience for listening to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. And if you found this podcast helpful, please rate and review or share the episode, and please follow Children's Health on your social channels.