PROJECT SUMMARY
Despite an increased investment in primary care screenings to identify the psychosocial needs of caregivers
and children (e.g., exposure to violence, racism, and insecure housing), these efforts don’t always result in
family-centered service referrals and follow-up to ensure all needs are getting met (i.e., families able to access
services such as housing and behavioral health support). When psychosocial needs aren’t identified or
addressed during childhood, it can cause or worsen children’s health conditions, interrupt their development,
and, at the societal level, perpetuate disparities in overall health. Our preliminary data identified key strengths
and weaknesses within families’ journeys through psychosocial screenings, service referral and linkage
processes in primary care – which we term “service pathways”. The goal of the current study is to optimize
the post-screening pathway to increase family referral and linkage follow-up, so that all screened families
receive consistent services. We hypothesize that clinics using our proposed adaptive intervention package will
increase family referral and linkage follow-up compared to clinics using current screening practices. This
study will scale up preliminary work in a large safety net healthcare system to optimize referral-to-
linkage service pathways. Process Service Mapping (PSM) is a novel and generalizable methodology that
actively engages partners to better understand how processes actually work, and ways to optimize service
pathways. PSM maps patients’ journeys using iterative cycles to identify inequities, challenges, and action
points. This study will scale up previous work by testing the CARELOOP Intervention (Clinics cAtch needs,
REfer, Link to services, and close the lOOp using an equitable family-centered Process). CARELOOP is a
system-level intervention designed to enhance psychosocial screenings through PSM methodology and
Implementation Science, and grounded in the Clinical-Community Relationships Evaluation framework. Denver
Health is a large safety net system serving minoritized families and 11 pediatric clinics already screen for
psychosocial needs using the Health-Related Social Needs and Survey of Well-being of Young Children. Our
main hypothesis is that intervention clinics implementing CARELOOP will have higher Service Referrals and
Linkages compared to standard care control clinics. After optimizing service pathways (Aim 1), we will conduct
a cluster-randomized trial to test the impact of CARELOOP on effectiveness (Aim 2) and implementation
outcomes (Aim 3). The study goals are: Aim 1: Engage clinics and communities to refine CARELOOP by
mapping service pathways to include equity and family-centered elements and tailored strategies; Aim 2: Use
a parallel-arm cluster randomized trial to test the effectiveness of the CARELOOP intervention; and Aim 3:
Conduct an implementation evaluation. This R01 study leverages current psychosocial screenings to rigorously
test an intervention designed to increase service referrals and linkages. We bring quality improvement,
implementation science, and novel co-creation engagement to accelerate family-centered care.
