DULCE: A Multi-Sector Approach to Addressing the Social Determinants of Health During and Beyond the COVID-19 Pandemic

Developmental Understanding and Legal Collaboration for Everyone (DULCE) is a universal, evidence-based pediatric care innovation that addresses the social determinants of health and supports relational health for families with infants in communities that are under-resourced and have been marginalized by racist systems. As the United States grapples with COVID-19, existing inequities have been exposed, bringing greater attention to this country’s flawed social and economic structures [1,2,3,4]. Millions of people are out of work and grappling with access to adequate food, housing, and other necessities. The pandemic has highlighted the need to address the social determinants of health, particularly for children and families of color [5,6,7].

DULCE facilitates a multi-sector collaboration between early childhood, health, and legal systems to transform the way families engage with pediatric care and addresses the social and economic challenges they encounter. The model is driven by the Strengthening Families Protective Factors Framework, anchoring the approach around families and their strengths. DULCE operates in pediatric health settings, supported by a robust local early childhood system-building organization. A specialized Community Health Worker, known as a Family Specialist, is part of the local pediatric care team and works to enhance routine visits during the first six months of an infant’s life. As the medical provider champion provides clinical care and developmental guidance to families, the Family Specialist develops a trusting relationship with the family, meeting with them before and between routine visits to not only understand but also to address the social and economic stressors that can create barriers to a parents’ bonding time with their infant. To accurately assess needs, the Family Specialist conducts screenings for concrete supports and mental health needs.

Dulce Id TeamAs part of a broader team of experts, the Family Specialist, along with the medical provider champion, a legal partner, an early childhood systems representative, a clinic administrator, and mental health representative meet weekly to review positive screens and identify appropriate services or resources to assist families. The Family Specialist then follows-up with families to ensure positive screens are addressed and families are thoroughly supported between routine visits. The integration of the early childhood systems representative provides access to an array of available services and supports while the legal partner addresses barriers to concrete supports families may encounter. Both enhance the pediatric medical home [8] by providing resources and support beyond what is traditionally offered in clinics.

The team-based approach also positions communities to systematically identify patterns and gaps in the resource and service landscape that might otherwise go unnoticed—providing these same communities with an opportunity for local advocacy. Through systems collaboration that leverages the expertise of an Interdisciplinary Team that includes among others a Family Specialist, medical provider champion, legal partner, and early childhood systems representative—the essential elements of DULCE come together to address the social determinants of health for families.

At the heart of the DULCE collaboration are the cultivated relationships, which support mutually beneficial outcomes for both families and systems. The Family Specialist cares for families during a critical period of relationship-building between parents and their infant. Family Specialists are training in Touchpoints, an evidence-based relational approach to increase the family’s knowledge on child development and enhance the relationship between the parent and infant to support parent resilience and confidence. The approach also allows for a stronger relationship between the family and health system. An Interdisciplinary Team creates opportunities for cross-sector pollination that improves the quality of holistic care provided to families and facilitates greater alignment between systems. As one DULCE medical provider champion put it, “Several years of implementing DULCE has helped us build a network of services in our city and within our hospital system. This has made our team and our Family Specialist, in particular, a focus for other groups at the hospital interested in addressing social determinants of health.” 

The coordinated network of relationships has supported positive outcomes. Of those families offered DULCE, 98% chose to enroll and 87% completed the program. DULCE also achieves high linkage rates for concrete supports and resources related to maternal depression and intimate partner violence. Through the DULCE collaboration, the Family Specialist and Interdisciplinary Team can enhance the pediatric medical home by increasing its capacity to respond to the social and economic hardships that families experience.

Through the coordinated efforts of the Family Specialist with the broader Interdisciplinary Team, and relationships between families and community supports, DULCE is adaptable in the face of disruption. Due to social distancing regulations, Interdisciplinary Team virtual meetings continue, and draw upon the expertise of legal partners and early childhood systems representatives to assist families to navigate complex COVID-19-related policies and guidelines. Given the network of community resources already established through DULCE and the knowledge and broad reach of the Interdisciplinary Team, they can quickly identify and deploy supports to families during this crisis.

There is no greater moment than now to support those greatly impacted by the COVID-19 pandemic. As one DULCE legal partner reminds us, “The crisis has really shown how interconnected services and legal systems are, and it is nice to have an Interdisciplinary Team that can collaborate. In a time where many are isolated, it is helpful to have the pediatrician’s offices as a regular check-in point for families who may have other needs but be too overwhelmed to access those services or who may not know how given the changing landscape.”

To learn more about DULCE and the randomized control trial highlighting DULCE’s evidence, click here. If you are interested in bringing DULCE to your community, contact Azieb Ermias at azieb.ermis@cssp.org.

  1. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930893-X
  2. https://www.apmresearchlab.org/covid/deaths-by-race
  3. https://developingchild.harvard.edu/thinking-about-racial-disparities-in-covid-19-impacts-through-a-science-informed-early-childhood-lens/?utm_medium=email&_hsmi=87370751&_hsenc=p2ANqtz-_gLeYvQPFQgumQevFdD2TpRoWxznxQkJDKzzSxa6ofxV3YIaDYRalsndDVw-gsI–aBwB_&utm_content=87370751&utm_source=hs_email
  4. https://www.samhsa.gov/sites/default/files/covid19-behavioral-health-disparities-black-latino-communities.pdf
  5. https://www.ahip.org/wp-content/uploads/Improving-Access-to-Care-for-Communities-of-Color.pdf
  6. https://www.urban.org/urban-wire/many-families-are-struggling-put-food-table-we-have-do-more?cm_ven=ExactTarget&cm_cat=UIU+-+5.14.2020&cm_pla=All+Subscribers&cm_ite=https%3A%2F%2Fwww.urban.org%2Furban-wire%2Fmany-families-are-struggling-put-food-table-we-have-do-more&cm_ainfo=&&utm_source=%20urban_newsletters&&utm_medium=news-UIU&&utm_term=URBAN_COVID19&&
  7. https://www.healthaffairs.org/do/10.1377/hblog20200420.92256/full/
  8. Johnson K, & Bruner, C. A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health. Child and Policy Family Policy; 2018.