How do I avoid burnout?
Screening for and addressing maternal depression or social determinants of health concerns can be very meaningful to both the family and practice staff. Doing so can enrich primary care by building stronger relationships between providers and families and mitigating the effects of circumstances that can negatively impact children's health, development, and safety. In the context of a culture that supports staff wellness, this process is rewarding; without such supports, there is a risk of chronic, vicarious trauma, sometimes called "compassion fatigue," which can lead to poor patient care and high staff turnover. Vicarious trauma is identified by the American Counseling Association as the "emotional residue" that health care providers experience after discussing pain, fear, and hardship with patient families6. One can mitigate these effects through good self-care practices, increasing awareness of the impact of stress, encouraging a supportive organizational culture, and implementing reflective supervision to address feelings that come from patient interactions7. Clinicians also report that incorporating strengths-focused dialogue into conversations can offset internalization of suffering through a focus on the positive aspects of a situation.
Refer to the Center for Health Care Strategies, Inc. staff wellness infographic for more information. I don't have time to do all this, how do I prioritize?
Creating and implementing a practice workflow for screening, referral, and follow-up and/or using a team-based care model can help to alleviate time constraints by making the process more efficient. Many practices have found ways to incorporate the AAP's screening recommendations into their well child visits. However, it can take time to find the process that works best for your practice. Start with small steps (perhaps adding one new screening for one visit) and build from there.
Some aspects of the process will improve over time, as providers build up their clinical skillset. Offering training opportunities to bolster knowledge, attitudes, and skills can help staff members become more competent and comfortable in these areas. When warranted, access the support of a care coordinator, behavioral health professionals or social workers to help.How do I advocate within my system for needed supports for screening, referral, and follow-up?
Share with your colleagues the evidence that substantiates the importance of screening and the need for early intervention to make long-term impacts on child and family health. Communicate about the workflows that practices have used to successfully integrate screening within the time constraints of the well-child visit. Point them to the resources related to coding and billing for further information about how to receive payment for these services. What is the difference between surveillance and screening?
Surveillance is a longitudinal, continuous process based on clinical judgement that includes eliciting and attending to concerns, maintaining a history of findings, making observations, and identifying risk and protective factors. The AAP recommends conducting surveillance at every visit. Screening should occur at the recommended visits using a validated tool for developmental and maternal depression screenings, or when a concern is expressed. For social determinants of health, it is recommended to use a tool appropriate to the patient population at every visit. The population that my practice serves is primarily middle class or affluent. Why do I need to screen for social determinants of health?
Adverse Childhood Experiences (ACEs) such as abuse, neglect, substance use by a parent, and parental divorce happen in every community. In fact, the CDC-Kaiser Permanente Adverse Childhood Experience (ACE) Study -- one of the largest investigations of the impact of ACEs on health -- found that among almost 20,000 participants, who were predominately white and middle-class with some college education, 26% had experienced at least one ACE.
In addition, though less common in some areas, poverty does occur in every community. A job layoff can leave a previously affluent family suddenly struggling to make ends meet. It is impossible to tell by looking at a child whether the family is experiencing financial strain.
Screening only certain families attaches stigma. Universal surveillance and screening is recommended for every practice. You can explore further resources and tools for screening for social determinants of health on this site.