Benefits of a Universal Intervention in Pediatric Medical Homes

On July 18, Academic Pediatrics, the official journal of the Academic Pediatric Association, published new evidence of DULCE’s impact, highlighting the strength of universal interventions in identifying family needs. 

DULCE, or Developmental Understanding and Legal Collaboration for Everyone, promotes the health and well-being of infants and their families, starting in the critical first six months of life. The DULCE Family Specialist, a specialized community health worker, meets with families as they bring their new baby for routine healthcare and partners with them to help the family get the support needed to raise healthy infants.  DULCE brings together a powerful cross-sector team of healthcare providers, early childhood systems representatives, and legal advocates. The team helps to effectively address the social determinants of health for families and combat systemic barriers to their well-being. 

Critical to DULCE’s approach is that every family that brings their infant to participating healthcare sites is offered services. DULCE operates in pediatric medical homes in underserved communities, where historic and structural injustices have resulted in disinvestment and barriers to well-being. Families who seek care at DULCE clinics are universally invited to enroll, and DULCE families are universally screened for health-related social needs (HRSN) and connected to resources that address family priorities. This universal approach means that any family can access DULCE’s services, promoting equity without contributing to exclusion.  

The new study of DULCE compares HRSN screening and resource connection outcomes from DULCE’s universal approach to expected outcomes if a targeted approach–i.e. one which uses observable family characteristics to determine eligibility to receive services–had been applied. Data from eight DULCE sites across three states serving 1677 families between January 2017 and May 2020 showed:

  • More than half of the DULCE families did not meet four traditional risk criteria (income, foster care, first-time parent, teen parent) utilized by targeted programs had HRSN: 
    • Very few of these families were accessing resources at DULCE enrollment; half were connected to resources during DULCE participation. 
  • Most (72%) of families with HRSN would have not been identified if risk-based enrollment criteria had been used.
  • Many of the families who were already utilizing HRSN resources before DULCE , including SNAP, WIC, and TANF, had unmet needs at DULCE enrollment.

As this is the first study (to the authors’ knowledge) to analyze the impact of universal, pediatric clinic-based approaches on families in under-served areas, its implications for policy and practice are powerful. From these results, we see that: 

  1. Traditional risk criteria used by targeted interventions are imperfect predictors of family need.
  2. Existing support structures alone do not fully meet the needs of families. 
  3. Universal approaches delivered through pediatric medical homes can play a key role in early childhood systems’ support of healthy development for all families. 

Traditional risk criteria used by targeted interventions are imperfect predictors of family need. 

Targeted interventions utilize specific characteristics of families to direct benefits to those deemed “higher-risk,” often designating first-time parents, teen parents, foster families, and low-income families as those most in need of services. Though intended to optimize service delivery, risk criteria are imperfect proxies to determine who needs support. In contrast, the DULCE approach adds a relational approach to the standard evidence-based screens, effectively allowing parents a key role in determining their own family needs.

DULCE welcomes all families to enroll and systematically screens all families for HRSN.  DULCE prioritizes family engagement in risk assessment, administering evidence-based screens using relational health strategies that center parents in their care. As a result, DULCE was able to identify HRSN in more than half of the families who would be ineligible for targeted services. This suggests that relying on family characteristics–including age, income, or number of children–in place of relationship-based screenings does not accurately capture whether a family has HRSN and demonstrates the value of parent engagement.

Existing support structures alone do not fully meet the needs of families. 

Every DULCE family is screened for HRSN, regardless of whether they are already participating in support programs. DULCE’s universal screening tactics revealed evidence that many families already using HRSN resources still have unmet needs. The study found that 68.6% of families who met traditional “high-risk” criteria had unaddressed HRSN, with 63.9% accessing additional services through DULCE. This confirms what we already know: that existing support structures are often insufficient. 

Not only can current systems fail to provide adequate support, but these systems are often siloed. HRSN are not independent of each other, with families often experiencing multiple HRSN across different areas, but support systems are not built to account for this. To meet their needs, families must access multiple programs, which creates logistical barriers to achieving well-being. DULCE acknowledges the importance of cross-sector collaboration, bringing together the strengths of multiple sectors to facilitate comprehensive, easily accessible support. In follow-ups with families about their screening results, DULCE Family Specialists (specialized community health workers) work to meld their knowledge of community resources with family goals and priorities, engaging families in determining how best to navigate support.

Universal approaches delivered through pediatric medical homes can play a key role in early childhood systems’ support of healthy development for all families.

Systems intended to support families with infants in low-resource communities may miss nearly three quarters of families with HRSN if we use targeted approaches exclusively. These consequences are heightened in under-served, under-resourced communities which have been historically overlooked.

If relied upon exclusively, risk-targeted approaches are insufficient to improve population health because many families are left behind. Universal programs provide the opportunity to ensure that all families have the potential to improve their health and well-being. Ideally, these two approaches can work in tandem to optimize early childhood systems; universal, medical-home based interventions can meet some families’ needs, identify other families who need and want more intensive targeted support, and facilitate warm handoffs to community resources.

In addition to failing to accurately predict whether families need support, the use of risk criteria in aid programs risks further stigmatization. Families traditionally marginalized by systems often have trouble trusting support services. Eligible families may turn down benefits services, leaving their needs unmet. Universal approaches eliminate stigma, increasing the likelihood that families will access available resources. DULCE further meets families in pediatric clinics where they are already seeking care, and through culturally responsive, relational practices, creates a safe environment where families can trust that their needs will be met without fear of judgment. 

Moving Forward
From this work, we can see how systems may reconsider how best to serve families. Pre-screening based on demographic characteristics alones misses many families in need. Second, offering services to all families – and then providing processes for collaboratively determining needs, priorities, and preferences – shows a fundamental respect for the dignity of every family.  In our previous publications, DULCE has shown how supporting embedded community health workers in care settings increases the reach of available services. Finally, although not the subject of this paper, programs like DULCE  reveal important gaps in existing support. 

Effective means to address health-related social needs may benefit from designing a portfolio of approaches: the intensive supports of targeted interventions can be offered in combination with universal approaches, like DULCE, which offer support to all families. This portfolio approach provides the opportunity for individualized, holistic, convenient support towards achieving the health and well-being that both parents and local systems seek.