Implementing social risk screening across a pediatric liver transplant learning health network: Lessons from the Starzl network for excellence in pediatric transplantation

BACKGROUND: Social adversity contributes to poor health outcomes for children after liver transplantation (LT), including greater morbidity and mortality. Although social risk screening is standard practice in pediatric primary care, its adoption in pediatric LT (pLT) remains limited, despite the significant prevalence of social risks among these families. 

OBJECTIVES: To evaluate barriers and facilitators to social risk screening implementation in pLT settings across a multicenter learning health network. 

RESEARCH DESIGN: A mixed-methods study utilizing surveys and semistructured interviews. 

SUBJECTS: Health care practitioners involved in pLT care across North American centers in the Starzl Network for Excellence in Pediatric Transplantation (SNEPT) Network. Participants included multidisciplinary team members, notably transplant physicians, social workers, and research coordinators. 

MEASURES: We surveyed center leads to identify center-level implementation challenges. We conducted 1-on-1 interviews with transplant team members to identify barriers and facilitators. We analyzed qualitative data using the Capability, Opportunity, Motivation-Behavior model, an implementation science model for developing targeted interventions. 

RESULTS: We surveyed 10 centers, of which 40% of liver transplant clinics reported actively screening patients for Social Determinants of Health (SDoH). Most practitioners indicated reliance on social workers and cited limited resources as barriers to implementation. We also conducted interviews with 18 practitioners across 11 centers. Reported barriers included uncertainty about the tool's added value, time and space constraints during patient encounters, and challenges with data entry and sharing across a multicenter network. Facilitators included institutional support, interdisciplinary collaboration, and integration into electronic health records. 

CONCLUSION: Efforts to increase adoption should focus on improving practitioners' experiences with the tool as well as further assessing and disseminating its potential value in improving outcomes. Strategies for addressing logistical challenges to adapting workflows and simplifying network data management should be considered. This study establishes a foundation for improving screening rates and data capacity.