The pediatric clinic at St. John’s Episcopal Hospital, located at 495 Beach 20th Street in Far Rockaway, Queens, is small. It is headed by Dr. Cynthia Criss, a board-certified pediatrician; she is supported by four other pediatricians (totaling 1.5 FTE), two medical assistants, a half-time nurse/lactation specialist, and, beginning in 2018, a grant-funded social worker. The clinic shares space with the hospital’s family practice clinic. The pediatric clinic sees approximately 800 children under 5 annually. 

The Rockaway community is culturally, racially, and economically mixed. Eighty percent of the clinic’s patients live in neighborhoods that are medically underserved for primary care. About 30% of the community is foreign-born, principally from Latin America but also from Africa and Asia. More than 20% of the children have family incomes below the federal poverty level; 90% are insured by Medicaid.

The Rockaways are also home to major public housing complexes, totaling 3,500 apartments across five locations, with approximately 10,000 residents. The local economy is still recovering from Hurricane Sandy, which eroded its Atlantic beaches and damaged or destroyed many modest homes and local business structures.

St. John's Episcopal: Key Elements

Dr. Criss began the process of incorporating a screen for socioeconomic needs into her practice structure in 2017. Her twin goals were to:

  • establish a formal referral mechanism that would link patients and their families to social services providers for non-medical support services
  • collect data on the nature and extent of those needs among the families in her practice

She negotiated partnership agreements with Sheltering Arms, a local community organization that could provide child care, summer camps, and social services to families, and the Queens Family Resource Center, which offers parenting classes and help accessing public benefits. In 2019, due to its limited resources, Sheltering Arms had to withdraw from the partnership, and was replaced by the Ocean Bay Community Development Corporation. The Corporation provides wrap-around services for public housing residents, such as assistance with applying for public benefits and referrals to other community resources. 

The clinic uses a survey tool that asks about multiple different needs—child care, behavioral problems, housing, and food insecurity. Parents are given a paper survey to fill out in the waiting room when they come in for a well-child visit. The completed survey is collected by the clinical staff and responses discussed with the families. Parents are then directed to one of the community organization partners for assistance, and clinic staff sends the necessary referral information to the appropriate partner organization so that its staff can contact the family. Clinic staff also enter the screening results and referral information on a spreadsheet for tracking purposes. 

By 2018 the screening and referral program was well established in the clinic, but many of the families with unmet needs did not take advantage of the community organizations’ resources. Dr. Criss therefore decided to add a social worker to the clinic staff to work more closely with families, especially those with urgent needs. The social worker explains the referral process to parents, gives them an informational flyer about the community organization and its services, and follows up with phone calls and emails to the families. She also works closely with the partner organizations to be sure they have the information they need to contact the referred family, especially for families with urgent needs.

“Adding the social worker to our staff has been incredibly valuable,” says Dr. Criss. “She helps build trust between the clinic and our parents and they are more willing to accept assistance. We hope to see a difference in health care gaps and positive long-term health and wellness outcomes as a result.”