• PROJECT LEAD(S): Lan Vu, MD, MAS; Doruk Ozgediz, MD, MSc
• EXECUTIVE SPONSOR(S): Atsuko Baba, MD; Hanmin Lee, MD
• ABSTRACT - One paragraph summary of your proposed initiative – Limit 1500 characters (with spaces)

There is growing literature on the importance of social determinants of health (SDoH) on surgical quality outcomes in the pediatric population.  Patient navigator programs have been shown to address and minimize the impact of SDoH at multiple levels.  In addition, these risk factors have been shown to be associated with surgery same day cancellations, which impacts access to equitable health care for children.  We propose to develop community-based patient navigator program as an intervention to provide resources for high risk patients, identified by individual and neighborhood-level SDoH screening.

TEAM - 
Matt Pantell, MD, MS (Pediatric Hospitalist whose research and clinical areas of interest include interventional programs to address health equity): Mentor
The nurse practitioners who will performing the individual-level SDoH screening (Amanda Parker, NP, Anne Hagbom, NP, Mellany Aquino, NP, Bianca Juarez, NP, Megan Drombroski, NP, Jessica Pascual, NP)

• PROBLEM – Surgical quality outcomes is strongly tied to social determinants of health (SDoH) in the pediatric population.  Recent literature highlights the impact of race and ethnicity on postoperative mortality in healthy children. Compared with being white, African-American children had 3.43 times the odds of dying within 30 days after surgery, 18% relative greater odds of developing postoperative complications, and 7% relative higher odds of developing serious adverse events. (Nafiu et al, JAMA Surg, 2020).  Looking specifically at our institution’s pediatric cohort, 12% of the NSQIP-P population had high Social Vulnerability Index (SVI) and this was associated with postoperative complications. (Yap et al, Am J Surg, 2023).  Currently, there is variability in SDoH assessment of the surgical population and limited resources to address these risks when they are identified (Sokol et al, Pediatrics, 2019).  Patient-navigator programs have led to improved processes of care, patient experience, clinical outcomes and costs for children with chronic conditions (McBrien et al, PLoS One 2018). Surgery same day cancellations is an important metric to assess the success of the Pre-Surgery clinic at UCSF.  There has been a recent uptrend in the reasons for same day cancellations of late arrivals and no shows, which may be secondary to modifiable SDoH risk factors.  The mechanism to screen for SDoH (financial resource strain, food insecurity, housing stability, and transportation needs) currently exist in the UCSF Epic system.  However, there is minimal social worker resource in the Pediatric Pre-surgery clinic to address these needs when identified. 
• TARGET -  

Outcome metrics:

1. Distribution of individual-level and neighborhood-level SDoH in our current surgical patient population
2. Successful contact with families by the patient navigator
3. Surgery same day cancellations rates before and after implementation of patient navigator program
4. Comparing individual-level SDoH with neighborhood level-level SDoH (SVI) and their impact in on the surgical outcomes in the NSQIP-P database.
5. Results of satisfaction survey

 The expected benefits include decline in of the number of same day cancellations based on modifiable reasons (ie no shows and late arrivals), improved patient experience and patient/families satisfaction in the immediate study period. In the long term, we expect improvement in surgical quality outcomes as assessed through the NSQIP-P database which may allow us to determine the role/impact of individual versus neighborhood-level SDoH. 

• GAPS - Why does the problem exist?  Describe system issues; technological gaps; educational gaps

The mechanism to screen for SDoH (financial resource strain, food insecurity, housing stability, and transportation needs) currently exist in the UCSF Epic system.  However, there is minimal social worker resource in the Pediatric Pre-surgery clinic to address these needs when identified. In addition, social worker does not address the barriers at the community level which would be the focus of the patient navigator program.   

• INTERVENTION 

Study Design:
Phase 1: Patient Navigator training program: URM medical students or post-baccalaureate students from the community (trained by professional Patient Navigator at ZSFG)

Phase 2: Intervention
1. SDoH screening at Prepare clinic appointment:

• 8 screening questions on Epic: financial resource strain, housing stability, food insecurity, transportation needs, utilities to assess individual-level SDoH
• Automated geocoding of addresses in Epic into SVI to identify neighborhood-level SDoH
• Patients/families identified as high risk for any of the categories will be given access to resources in local community (https://www.findhelp.org/) and asked to participate in Patient Navigator program.
• SDoH risk assessment entered into NSQIP-P database by SCR (surgical clinical reviewer)

2. Intervention Phase:

• 1^st call: provide local community resources before procedure date
• 2^nd call: follow-up one week after procedure
• 3^rd call: follow-up one month after procedure
• 4^th call: follow-up two months after procedure (satisfaction survey)

Study Duration: one year

Patient Population:

All children who will be evaluated at Pediatric Prepare clinic before scheduled procedure at BCH SF, plan to expand to BCH-Oakland after pilot period of 3 months at BCH-SF

Sample size: total 7,000 surgical procedures (1500 anesthesia nonsurgical procedures), about 50% of cases are scheduled outpatient cases

Current proportion of cohort considered high risk for SDoH: estimated 12% (based in NSQIP-P data)

Estimated N=420 patients (high risk)

• PROPOSED EHR MODIFICATIONS Individual-level SDoH screening questions already exist as part of the storyboard on Epic. We are requesting the addition of neighborhood-level SDoH assessment be included into Epic by geocoding the home addresses and converting into SVI percentile (1-100, higher percentile notates higher level of social vulnerability).  The algorithm has already been developed (Yap et al, J Am Surg, 2023).

• RETURN ON INVESTMENT (ROI) Estimated direct cost savings to the health care system cannot easily be calculated. However, decrease in surgery same day cancellations will allow for better OR block time utilization, leading to improved revenue.  Decrease postoperative complications would impact health care costs as documented in the NSQIP-P database (include postop ED visits, hospital readmissions, and hospital length of stay). 

• SUSTAINABILITY -If successful, the patient navigator program will be sustained by hiring one full-time patient navigator to train and coordinate the program.  Medical Director of Pediatric Perioperative Services (Dr. Atsuko Baba) and Surgeon in Chief for the UCSF Benioff Children’s Hospital in San Francisco (Dr. Hanmin Lee) are both executive sponsors for this proposal and are committed to providing operational resources and funding after the project year.

• BUDGET - Line-item budget up to $50,000 - Briefly identify key areas of the project that will require funding, e.g., salaries, software, printing, etc
  0.5FTE Patient Navigator: train volunteer patient navigators:           $30,000-40,000 (based on annual salary of $60,000-80,000)
  0.1FTE RN or MD director                                                                 $10,000-20,000

Center for Health Equity in Surgery and Anesthesia (CHESA) and the Division of Pediatric Surgery have expressed commitment to providing additional funding if needed to support this program.