Children’s hospitals and health systems aim to improve children’s health by providing clinical care and addressing the social drivers of health within their communities. Social drivers of health (SDoH) include the conditions in the environments where people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Eighty percent of health and health care outcomes can be attributed to factors such as safe and stable housing, access to food and transportation, social connection, and safety or environmental exposures. Addressing a communities’ SDoH can improve health outcomes but takes a comprehensive approach with many sectors of society working together. These efforts are part of children’s hospitals’ and health systems’ commitment to provide health care for all children and address social drivers at the patient, family, and community levels. Early intervention and prevention of chronic health problems can lead to a healthier adult population, stronger workforce, and reduced costs.
Food insecurity
Nemours Children’s Hospital, Delaware in Wilmington partners with the Food Bank of Delaware to stock nonperishable food pantries at two outpatient offices for families with immediate needs. In addition, Nemours Children’s Health, Jessup Street partners with Bushels of Blessings, which provides fresh summer produce to distribute in the office.
St. Joseph’s Children’s Hospital of Tampa in Florida has developed several initiatives aimed at addressing food insecurity. Among them is a “food clinic” model where providers screen all patients coming through the hospital for food insecurity and can provide them with a prescription to the food clinic so they can access fresh and healthy foods including produce and frozen meats.
In Aurora, Children’s Hospital Colorado installed a 3,000-square-foot community garden on their hospital campus to provide the produce for their Healthy Roots Food Clinic, which serves families from their primary care clinics who screen positive for food needs. In addition to a weeks’ worth of groceries for the household, the food clinic also provides personalized nutrition education, support, and assistance enrolling in public benefit programs like the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
A grocery store on wheels was created to serve selected counties around Fort Worth, Texas, through a partnership between Cook Children’s Medical Center, Tarrant Area Food Bank, and H-E-B Hunger Relief. This refrigerated trailer has shelves stocked with fruit, vegetables, and dairy products and connects families to SNAP and other community resources.
Through a partnership with Houston Food Bank, Texas Children’s Hospital has on-site food bank navigators that assist families with applications for public benefits such as SNAP and connects families to community resources.
Housing
In 2003, Connecticut Children’s Medical Center in Hartford established the Healthy Homes program to improve health outcomes for children by removing hazards from their homes. Since its inception, 3,000 homes now have safe and healthy environments. Launched to primarily address lead hazards, the program has expanded to include additional health concerns such as asthma, radon, and safety-related injuries.
Children’s Wisconsin in Milwaukee has developed a centralized lead program to close care gaps and support care for children impacted by lead poisoning, which stems from degrading paint, soil, and plumbing sources in older homes and buildings. They identify patients who need lead tests and offer more in-clinic testing options. The centralized lead program coordinates the patient’s care and assists in addressing barriers. They also work with city health officials to provide education and support to families who need additional services or require lead abatement.
The Kinship Housing Project at Dayton Children’s Hospital will help kinship families develop stable and consistent relationships with relative or nonrelative children they are caring for within their homes. The project fosters housing stability, safety, and support for kinship families, many of whom live in substandard or age-restricted housing unsuitable for raising children. To address these challenges, the hospital is partnering with local architects, a construction company, a property management firm, and nonprofit community development agencies to build affordable housing units near the hospital. The design includes 13 structures that will accommodate two families each. The housing will have a minimum of three bedrooms, be ADA accessible, and include a shared greenspace for residents.
Children’s Nebraska partners with Healthy Housing Omaha, a community-based organization, to address environmental needs in the home for children at high risk for complications due to chronic health conditions. The organization offers home assessments to identify mold and other potential triggers and then completes mitigation and remediation at no cost to the family. The two main goals of the program are to reduce emergency department visits and improve overall quality of life for kids living with asthma and their families. Children’s Community Health and Advocacy assembled a multidisciplinary team that includes medical staff and social work to address patient needs and develop a program path from intake to project completion and follow-up patient assessment.
Transportation
In Salt Lake City, Primary Children’s Hospital boosts awareness of how Medicaid can assist with transportation to medical appointments, including wheelchair enabled vans or buses. In addition, the hospital can provide transit passes for the local bus or train system along the Wasatch Front. For the families that live in rural areas, transportation needs can be communicated through the Unite Us platform.
UPMC Children’s Hospital of Pittsburgh families can receive free transportation to their preventive care appointments thanks to a partnership with Lyft.
Economic support services and resources
While specific interventions are available related to food, housing or transportation, families who screen positive for health-related social needs often have multiple areas where they could benefit from support.
Yale New Haven Children’s Hospital in New Haven, Connecticut, partners with their local United Way 2-1-1 referral service to connect families with a variety of needs to community agencies that can assist them.
Children’s Mercy Kansas City provides Lift Up KC, a social care referral platform, to their patients and community providers, centralizing access to more than 3,000 programs hosted by community-based organizations (CBO). Individuals can use this social care referral program to connect with free or reduced cost services related to food, transportation, housing, employment, and more. Children’s Mercy created a trusted network of five, full-service CBOs across different geographic areas of the Kansas City metro. Each agency is provided with funding to support the use of the Lift Up KC closed-loop referral system. This model allows every community primary care practice to have one primary CBO to refer families for any SDoH need, and, as a result, significantly simplifies the workflow for staff and improves outcomes for families.
At The PLAYERS Center for Child Health at Wolfson Children’s Hospital in Jacksonville, Florida, navigators help community members apply for Medicaid and SNAP and connects families with emergency food supplies, legal services, child care, public transit passes, employment support, rent and utility assistance, clothing, and diapers. Families are referred by community agencies and by word of mouth.
Akron Children's Hospital in Ohio operates a Family Resource Center (FRC) that connects families, staff, and community members to resources in a central location. In addition to offering hospital services such as care coordination and translation and language access, the FRC has a Safety Center where families receive education and safety equipment such as car seats, portable cribs, medication lockboxes and gun locks. The FRC partnered with local agencies to offer an onsite WIC clinic, free financial counseling and tax preparation for eligible families and staff through United Way, family assistance for legal issues with Community Legal Aid, and child care assistance, SNAP, TANF benefits, and more with the Department of Job and Family Services.
At Blank Children’s Hospital in Des Moines, Iowa, the hospital offers Patient Compassion Funds to cover nonmedical expenses. Approximately $400,000 in donated funds are set aside annually to help families with transportation, gas, hearing aids, rent, utilities, food, clothing, diapers, and medication lock boxes for children with suicidal ideation.
Helping families achieve economic stability is a priority for the Boston Children’s Health Accountable Care Organization (BCH ACO). Boston Children’s Hospital and its affiliated specialists and primary care physicians participate in the MassHealth ACO program. BCH ACO partners with the Massachusetts Association for Community Action and the Boston Tax Help Coalition to help patient families file their taxes and access the Earned Income Tax Credit. In 2023, the program helped families access over $35,000 in tax refunds and credits.
Nationwide Children’s Hospital began a comprehensive initiative — Healthy Neighborhoods Healthy Families (HNHF) — more than 15 years ago to improve community health and wellness with increased access to affordable housing and economic and employment opportunities for residents of two Columbus, Ohio, neighborhoods. The initiative, made possible through important community partnerships, has impacted more than 800 homes through home ownership or rentals below market rates and home repair grants. HNHF also offers career preparation classes, free tax preparation, and an adult financial mentoring program that includes a savings match — all designed to promote residents’ financial self-sufficiency. As a result of this initiative, more than $50,000 in savings matches and more than $5.4 million in tax refunds have helped participants find stable housing, pay off debt, or save dollars to meet important needs. In addition, Nationwide Children’s has hired more than 2,000 employees who have participated in the free career preparation classes.
In Little Rock, Arkansas Children’s Hospital's Medical-Legal Partnership is available at no charge to assist families with health-related legal needs, including guardianship, name changes and other family law matters, educational needs, housing, social security, and insurance.
At Doernbecher Children’s Hospital at Oregon Health & Science University in Portland, Oregon, Medical Legal Partnership attorneys assist families with legal issues related to housing insecurity, custody, and domestic violence. The goal of the program is to provide long-term stability for infants and families.
Through a partnership with Moms Helping Moms, Children’s Specialized Hospital in Mountainside, New Jersey, provides diapers, wipes, and other baby essentials to families who need them. According to the National Diaper Bank Network, approximately one in two caregivers experience diaper insecurity. Since its inception in 2020, the program has served over 1,000 families.
Northwell Health’s Cohen Children’s Medical Center in New Hyde Park, New York, implemented universal firearm access and violence risk screening for patients over 12 years in the pediatric ED. Screening consists of questions about firearm access within or outside the household, and a four-question SaFETy score, a validated tool to predict future firearm violence risk. If a patient is considered at-risk for firearm injury, they are provided with resources such as safety counseling, gun locks, and information about community resources such as violence interrupter programs.
Ann & Robert H. Lurie Children’s Hospital of Chicago supported new immigrants with a mobile health program for immunizations and emergent care at police districts and city shelters and will continue these programs as the need arises. The hospital has also strengthened its partnership with a local refugee organization to meet the basic needs of new arrivals with seasonal clothing, hygiene kits and toys, and information on available resources.
Education
Children’s National Hospital in Washington, D.C. is a school-friendly health system dedicated to helping children achieve optimal health and academic success. Through the Collaborative for Attendance Resources in Education and Health (CARE-H), a partnership with D.C. Public Schools and other organizations, the hospital works to reduce chronic absenteeism by aligning resources and supporting students. Since 2021, CARE-H has served 238 students, conducted over 4,000 minutes of outreach, and made nearly 100 referrals to medical and social resources, using a data-sharing agreement with DCPS to facilitate communication between pediatric practices and students’ families.
Children’s hospitals and health systems recognize that care extends outside the hospital walls. Addressing the social drivers of health for children and their families illustrates the organization’s commitment to improving children’s health and safety in all conditions of their daily lives.
