Family-Centered Community Health Worker Support for Children with Chronic Conditions and Unmet Social Needs

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PROJECT SUMMARY/ABSTRACT Addressing both care coordination needs and unmet social needs for children with chronic conditions is a high- priority goal for the United States health care system. Many children with chronic conditions live in poverty and have associated unmet social needs, such as food insecurity and housing instability, which can limit their access to care and lead to poor health outcomes. Their caregivers must navigate both complex health care systems and complex social service systems to access resources their children need to stay healthy. In my preliminary studies, I found that 51% of caregivers of children hospitalized with multiple chronic conditions reported having unmet social needs, and these caregivers expressed a desire for longitudinal care coordination support and assistance addressing their social needs after hospital discharge. In addition, I found that care coordination burdens disproportionately impact low-income, Black, and Hispanic children and are associated with forgone health care, perpetuating inequities in child health outcomes. To promote health equity and increase access to high quality medical care for low-income children with chronic conditions, there is an urgent need for effective family-centered interventions addressing both care coordination needs and social needs. Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized, theory-based, community health worker (CHW)-led approach to addressing care coordination needs and social needs for low-income adults with multiple chronic conditions. The intervention builds on CHW's lived experience and expertise and their unique ability to serve as a bridge between health systems and communities. IMPaCT includes three key components: (1) development of a detailed, patient-centered care plan, (2) longitudinal support focused on addressing medical and social needs, and (3) connection with needed follow-up care. In multiple randomized controlled trials in adults, IMPaCT has been found to improve patient-reported quality of care while reducing acute care utilization. The goal of this application is to target, develop, and test a pediatric adaptation of IMPaCT targeting both care coordination needs and social needs for hospitalized children with multiple chronic conditions. My specific aims are to 1) Identify social needs that are associated with decreased access to preventive care and increased acute care use among hospitalized children with complex chronic conditions, 2) develop an adapted IMPaCT intervention for pediatric patients with complex chronic conditions and unmet social needs, and 3) determine feasibility and acceptability and assess preliminary efficacy of the pediatric IMPaCT intervention. This work is relevant to Special Emphasis Notice (SEN): NOT-HS-21-014: Health Services Research to Advance Health Equity, given its focus on adapting and implementing an evidence-based intervention to advance equity within healthcare delivery systems, care delivery for persons with multiple chronic conditions, and integration of social determinants of health and social needs care within healthcare delivery.