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.

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:


Policy Statements and Practice Recommendations

General Information on Social Determinants of Health

Screening Tools

Commonly Used Referral Tools and Platforms

Community Context and Capacity Assessment Tools