Addressing Social Determinants of Health in Pediatric Primary Care Practices: People + Technology = Successful Connections

Full Description: Pediatric health systems are increasingly implementing screening/referral programs to address the social needs of the communities they serve. In this session, we will describe how a family support model implemented at Children’s Minnesota leverages both people and technology to address the broader social conditions that impact health. The Community Connect program, launched in 2017, aims to connect families with community resources. Families may enroll in navigation services through social risk assessment during well-child visits, direct clinician referral or family self-referral. Families are offered a simple icon-based, multi-lingual screening form to assess food, transportation, legal assistance, household goods, housing, financial assistance, and childcare/education needs. Families interested in resource support are connected to a resource navigator, who is equipped with access to a community resource referral platform that enables personalized referrals based on each family’s individual circumstances. The team of navigators are intentionally hired from the communities they serve. This cultural congruency allows for critical relationship building and allows families to seek support in their own language. Between January 2018 and November 2021, 5,458 patients received at least one referral via the platform (NowPow, a Unite Us company). While navigators work with families (e.g. parents/guardians), referral data is captured at the patient (child) level. The majority of patients receiving a referral were 0-13 years old (63%), 19% were 13-18 years old and 4% were older than 18. Nearly all patients identified as a racial/ethnic minority. 42% of patients identified as Black, 39% as Latinx and 4% as White. Half of patients (54%) indicated English as their primary language, 35% Spanish and 9% Somali. More than 10 languages were spoken by patients including Oromo, Amharic, Hmong, French, Arabic and Vietnamese. Navigators used the platform to share resources in the patient’s preferred language and mode (text, email and/or print). A quarter of families receiving resources (1,280) engaged in bi-directional text message communication. Based on the family’s unique needs, navigators curated personalized resource lists, leveraging information about the family (e.g. address, age, language) to match the family to local community resources. In total, 92,188 referrals were shared with patients via 12,306 curated resource lists. Top referred services included food pantries (11,996), clothing (6,100), diapers (5,750), fresh fruits/vegetables (3,621) and English as a second language classes (3,463). Navigators referred families to 1,725 unique organizations offering 192 service types to support whole person care. Key success factors included embedding workflows in the clinical setting, staffing a team of multi-cultural, multi-lingual navigators and leveraging technology to enable both bi-directional text message communication and personalized resource referrals.

Abbreviated Description: It is well established that social factors, like food insecurity or housing instability, account for more than 80% of a person’s overall health. In this session, attendees will learn how Children’s Minnesota – an independent pediatric health system in the Midwest – has implemented a comprehensive social needs program that leverages a community resource referral platform to match families with community services personalized to their unique needs. Since program inception, (January 2018 to November 2021), almost 6,000 patients enrolled in the Community Connect program and received at least one referral via the resource referral platform. Based on the families’ needs, navigators used the tool to curate and share highly personalized 12,306 resource lists including more than 92,000 referrals.