The Pediatric Center at Gotham Health, Gouverneur is a general pediatric practice that sees approximately 2,200 children under the age of 5 annually. It is one in a network of six large community health centers and smaller neighborhood Gotham Health sites, and part of the NYC Health + Hospitals system. The NYU School of Medicine is its academic affiliate. The practice is housed in a modern facility on the Lower East Side of Manhattan; multiple other primary care services for both children and adults are located under the same roof and management.

While Gouverneur draws some of its caseload from the neighborhoods near the facility, many patients come from other parts of the city. Forty percent of the families are Spanish-speaking and 25% of them speak Chinese. The practice staff at all levels is bilingual in either Spanish or Chinese plus English.

Gouverneur: Key Elements

Gouverneur began exploring the option of incorporating screening for unmet social needs into well-child visits in 2017 and reached out to four well-established community organizations in the Lower East Side to join as its community partners in this effort: Henry Street Settlements, University Settlements, Grand Street Settlements, and Educational Alliance. Together they mapped local resources for families, developed the protocol for a screening and referral process, and crafted in-formational handouts the clinical staff could use to help inform parents about the types of services offered by each of the community partners.

Gouverneur already had experience with administering standard screening tools for child development. In 2016 they had added screening parents for traumatic experiences (Adverse Childhood Experiences, or ACEs) during their own childhood. Adding yet another screen for social needs to the practice workflow was challenging, but once an efficient integration was achieved, it could serve as a model for other Gotham Health pediatric practices as well.

Building that model took more time and experimentation than expected—ultimately more than 18 months. A key decision was to migrate to using a tablet for all screenings. This reduced the flow of paper for the medical staff and ensured that all screens were done at the correct intervals and with the correct tools. All the screening tools used by the practice—in English, Spanish, or Simplified Chinese—were loaded onto tablets and are used by the Gouverneur staff to conduct the screens.

Gouverneur also decided to enhance its community resource directory by using the electronic platform NowPow. NowPow’s auto-map function helps to identify referral resources outside the Lower East Side area. Gouverneur continues to look for opportunities to further automate and streamline the process, especially with respect to tracking referrals and incorporating the outcomes of those referrals in its own electronic records. 

Dr. Marion Billings, the director of the Gouverneur program, believes all the effort was worth it. “Introducing the social determinants of health screening,” she said, “both as a concept to our staff (from executive level to patient care) and in implementation with our families, has helped fuel a critical shift in focus towards the socioemotional development of our pediatrics patients. This is a Pediatric Department priority.”