KCA: Assess Social Health and Well-being

Topic

Measurable Actions

Timing

Patient/Family Concerns

Elicit and address.

All well child visits

Family Strengths

Assess and discuss.

All well child visits

Perinatal Depression

Screen using a validated tool, discuss all results, and follow up on positive screens, including a primary care intervention for the mother/caregiver, social-emotional screening of the infant, and referral, if indicated.

By 1 month and at 2- , 4- , and 6-month visits

Social Drivers of Health (SDOH)

Assess using practice-standardized tool, discuss results, and follow up on positive screens, including a referral, if indicated.

All well child visits

Social-emotional Development

Screen using an age-appropriate validated tool and discuss all results; follow-up on positive screens, including a referral, if indicated.

All well child visits

KCA: Address Identified Needs

Topic

Measurable Actions

Timing

Counseling Conversations

Explain how to use materials to support the family’s interests, concerns, identified needs, or screening/assessment results, if provided.

All visits

Referral and Follow-Up

Establish follow-up positive screens/assessments or identified interests/concerns, including a referral, if indicated.

Make an attempt to follow up on the status of the referral within 30 days to ensure the family is accessing support (ie, phone call to family or referral clinician, community resource, etc.

All visits

Visit Assessment and Plan

Is reflective of the shared decision-making process resulting from the discussions with the family during the visit by doing the following:

• Prioritizes family interests/concerns
• Considers family strengths/protective factors
• Partners with the family to find resources/referrals that meet the family’s needs (culturally responsive, family schedule, transportation, etc)
• Uses Z codes for secondary diagnoses/identified concerns

All visits