Promising Practices, Highlights, and Case Studies

The case studies presented here showcase several New York pediatric practices’ approaches to promoting child health equity in their daily work.

Cohen Children’s Medical Center, Northwell Health
Pediatric primary care center implements a screening and referral model with on-site navigators to facilitate patient’s linkages to community partners to address health related social needs.

NYC Health + Hospitals/Gotham Health, Gouverneur
A federally qualified health center pediatric practice incorporates a social needs screening and referral process to connect families to community partners to address health-related social needs and socioemotional development.

Theresa Lang Children's Ambulatory Center
High-volume pediatric practice clinic pilots a maternal-child health partnership with a community organization to focus on services for infants and their families--with caregiver support, screening for maternal depression, and addressing social determinants of health.

Mount Sinai Pediatric Associates
High-volume pediatric practice aims to optimize its existing electronic medical record system to reflect social needs screening results in patient records to facilitate clinician feedback and referrals for services.

Charles B. Rangel Community Health Center
Community health center partners with a community-based perinatal support organization to create a risk stratification structure and community health worker role that facilitates timely access to maternal depression support services. 

Pediatric Health Services at St. John’s Episcopal Hospital
A small-scale pediatric clinic in a linguistically diverse neighborhood expands and formalizes its social determinants of health screening and referral initiative with the recruitment of a social worker to act as a patient advocate and care coordinator.

Sunset Park Family Health Center at NYU Langone–Second Avenue
Pediatric clinic serving 4,000 children under 5 annually streamlined its screening and referral process by integrating a social needs screening tool into its EMR system and making information on referrals available to community organizations.