Addressing the Social Needs of Young Children and Families

Children with unmet social needs—such as food insecurity or housing instability—are at greater risk for chronic health conditions, developmental delays, behavioral problems, and poor educational outcomes. Well-child care visits are an opportunity to identify unmet basic needs and connect families to social services.  

This section discusses some of the challenges pediatric providers face in screening specifically for social needs, as well as some of the opportunities to engage in this work. (See Integrating Behavioral Health and Developmental Screening, an accompanying page on this site, for a separate discussion on screening for mental, behavioral, and developmental needs of young children.)

Challenges for Practices When Addressing Children’s Health-Related Social Needs

• Young children are the poorest demographic age group in the country, making it common for families with young children to have multiple unmet social needs.
• Addressing children’s unmet social needs requires identifying and addressing the needs of parents and guardians in addition to those of the child, but pediatric providers may be unfamiliar with community resources that can support families with these needs.
• Not all community-based referral platforms include robust directories of child- and family-focused service providers, such as early care and education centers or breastfeeding support.
• Social needs screening and referral processes are not usually reimbursed; further, while these interventions may improve a child’s long-term health and development outcomes, they are less likely to yield short-term health care savings, making it harder to make the business case for investing in child-focused social needs interventions.
• The need for services is no guarantee of access to services: 
  • Sometimes there aren’t enough providers of a service to meet the community’s needs
  • Sometimes other factors like scheduling, transportation, or safety make it difficult to get to reach services
  • Sometimes distrust makes parents reluctant to share information with health care providers or engage with social services

Strategies for Addressing Unmet Social Needs in New York State 

As evidence of the connection between social determinants of health (SDOH) and an individual’s long-term health outcomes grows, more and more health care settings, including pediatric practices, are working to address both SDOH and unmet social needs. These approaches include community-wide SDOH strategies to address social and economic factors that affect daily life (e.g., affordable housing developments), as well as individual social needs interventions to mitigate immediate conditions or issues a patient may face (e.g., medical-legal partnerships for eviction prevention). More examples follow.

• Establishing direct screening and referral partnerships between pediatric clinics and community-based organizations, like the NewYork-Presbyterian/Queens and Public Health Solutions electronic screening and referral pilot and other Partnerships for Early Childhood Development teams
• Deploying community health workers to improve housing conditions and care coordination for families to prevent asthma hospitalizations and missed school days 
• Engaging in collective impact initiatives such as United for Brownsville 
• Using Help Me Grow, a community-wide referral and systems improvement platform in Long Island and Western New York, to help families connect with human service agencies, educators, and health care professionals 
• Participating in federal initiatives, including the Accountable Communities for Health effort and the Integrated Care for Kids demonstration project

Providers who have successfully integrated screening and referral processes for addressing unmet social needs are now working on sustaining and spreading their models. This pioneering work includes:

• Closing the referral loop to inform next steps of patient care
• Training and developing the pediatric workforce on health disparities, health equity, and implicit bias
• Developing payment and reimbursement models to support SDOH screening and interventions

Getting Started 

Implementing a social needs intervention in pediatric practice for patients and their families has several interrelated components. Ways to get started include:

• Learning about social determinants of health in the community by reviewing social, economic, and health indicators at County Health Rankings, reviewing Community Vital Signs, or, for New York City only, Keeping Track Online
• Taking stock of the resources available in the community to address identified needs, using tools like HITE or Keeping Track Online’s Map Community Resources tool, or cloud-based platforms like Aunt Bertha and NowPow
• Exploring ways to use health information technology and electronic medical record systems to streamline the screening and referral process 
• Reviewing and comparing screening tools to determine what works best with the practice and the populations it serves
• Engaging parents in designing and providing feedback on the screening and referral process, from screen tool selection/development to referral administration
• Trying to understand the needs and concerns of parents and community members about screening
• Learning about and exploring use strengths-based approaches to screening

Resources