Mount Sinai Pediatric Associates is part of the Mount Sinai Hospital system and a training site for Icahn School of Medicine pediatric residents. Located at Madison Avenue and East 100th Street on the Upper East Side of Manhattan, it provides general pediatric services to more than 6,775 children under age 5 annually.  

Most of the children seen at the clinic live either in East Harlem or the Bronx. Approximately half of its patients are Latino, primarily Spanish-speaking; most of the remaining patients are Black. Medicaid insures 88% of the clinic’s patients. Asthma is a common chronic condition among children in the practice.

Mount Sinai Pediatric Associates: Key Elements

The Mount Sinai practice piloted its social determinants of health screening program in 2016, focusing solely on food insecurity. Families reporting food needs were provided information about Mount Sinai’s community partner, the New York Common Pantry. Screening results were incorporated in the patient’s electronic medical record (EMR), which helped clinicians be aware of the need and inquire about the family’s status at the next visit. 

In 2017 the practice kept the food insecurity screening process in place, but also responded to feedback from clinicians and families by piloting a second social needs screen. This screening tool asked questions about environmental issues (mold, vermin), government benefits, adult literacy, housing, and child development. The screen was administered in the waiting room by the social work staff, who then had to enter the results manually as a visit note on the patient’s EMR. The practice also added a second community partner to the program, Little Sisters of the Assumption Family Health Services. Staff of Mount Sinai’s Department of Environmental Medicine and Public Health also help families cope with home environmental problems. 

The staff and the families that participated in this broader screening pilot welcomed it, but expanding it to the entire practice was impractical without more staff. Therefore, the practice recruited a “Dream Team” of medical and public health student volunteers and added a screening coordinator to the practice staff. Together they manage the screening process, make referrals, enter data into the hospital’s REDCap database for tracking, and conduct telephone follow-up interviews with the families. 

Unlike the food insecurity screening, however, the social needs screening results are not integrated with the practice’s EMR system. To remedy that, and to streamline communication with their partner organizations, in late 2019 the practice undertook a two-step refinement of its process. First, the social needs screen and the food insecurity screen would be consolidated into one, and all the results electronically incorporated in the EMR. Second, the Mount Sinai information staff would customize the EPIC Healthy Planet dashboard, a population management system module for the practice EMR, to accommodate the pediatric screen. This would facilitate a link to the Aunt Bertha resource directory, which would allow practices to connect with community-based social care resources and also permit bi-directional electronic communication between the practice and its partners. Once completed, this initiative will dramatically enhance the practice’s capacity to assure patients are receiving timely screening and follow-up care.

The Mount Sinai leadership believes it is critically important that its pediatric interns and residents are familiar with the services their partner organizations provide. Interns visit both community partners as part of their orientation to the practice. Residents spend time with each of the service organizations, helping at the food bank, observing parenting classes, and getting acquainted with the staff. “These visits,” says Dr. Laura Zajac, director of the practice’s screening program, “are valued by the residents and greatly enhance their capacity to address the socioeconomic needs of their patients.”