Patients often need more than clinical care to support good outcomes. Social drivers of health — the nonmedical factors in people’s home and community — influence patients’ ability to manage chronic conditions and health risks.
Take eight-year-old Lucy, who is dependent on insulin that must be refrigerated and managed carefully. After Lucy was admitted to the hospital multiple times in diabetic ketoacidosis, a Children’s Wisconsin community health navigator reached out to Lucy’s mother and learned they were homeless. That meant they had no reliable way to refrigerate insulin and could not manage her diabetes well. Realizing their needs, hospital staff connected the family with resources, bringing more stability to their lives and predictability to Lucy’s medical care. Without the community health worker, clinical staff would not have had the complete picture of the family’s challenges, and Lucy’s health would have continued to decline.
Housing is just one of many social drivers of health that can influence 80% of health outcomes. Children’s hospitals and pediatric health care providers are uniquely positioned to identify social drivers and address them through partnerships and collaborations. Children’s Hospital Association collected feedback and experiences from 29 children’s hospitals and health systems, revealing six key lessons for successful screenings.
1. Be transparent
Educate families about the screening process to build trust. Share why the questions are being asked, how the information will be used, and what and when resources may be provided. Nationwide Children’s Hospital created a script for clinicians to use during screenings stating that all patients are being asked the questions and staff will contact the family if a need is identified. Then, the hospital requests permission to move forward with the questionnaire.
2. Don’t assume
Avoid making assumptions about needs based on perceived socioeconomic status. Children’s Memorial Hermann Hospital in Houston found positive screens occur in communities with higher economic status, which shows families with health insurance also have social needs pediatric health care organizations can address
3. Integrate families
Seek input from families when developing, implementing, and improving screenings. Children’s Specialized Hospital in New Brunswick, New Jersey, sought feedback from its Family Faculty, who are parents and family members of current or former patients. This group offers a unique perspective and empathy for families going through similar situations. Family Faculty helped the team implement social driver screenings in outpatient, inpatient, and long-term care settings. They also provided guidance on the hospital’s screening tool, the implementation process, and ways to build trust and safe spaces for these conversations. Involving families highlighted the importance of offering various screening modalities in the outpatient setting — including text, email, or assistance of a family navigator — to allow families to respond in a way that is most comfortable for them.
4. Understand cultures
Tailor screening efforts to patients’ social, cultural, and linguistic needs. Children’s Minnesota hires resource navigators from its diverse communities who have a better understanding of families’ unique needs. These navigators connect families to resources within their network of community partners and make warm handoffs. The navigators follow up over time and ensure families have access to the resources they need.
5. Expand slowly
Pilot new screenings in one area before expanding across the hospital or system. For example, Children’s Health in Dallas began its systemwide implementation in ambulatory settings in July 2022, followed by inpatient settings in February 2024, and expanded to the emergency department in July 2024.
Timing has been critical to ensure successful implementation. The team planted the seed early, shared why this work is important, and identified staff to serve as champions throughout the implementation process. Staff helped design workflows and integrate social drivers into the electronic health record. In addition, they developed presentations, computer-based training modules, and an interactive resource guide for the teams involved with the program.
Cincinnati Children’s created a task force to develop an institutional approach to screen for social drivers, depression, suicide, and substance use. The hospital found screening was not taking place in a standardized way across the organization. As a result, staff identified early-adopter groups and now use their experience to make recommendations on how to scale standardized efforts across the organization.
6. Keep refining
Continue to improve the quality and efficiency of social driver screenings. Nemours Children’s Health in Delaware and Florida has taken a Plan-Do-Study-Act approach, a standard quality improvement process. The six-phase process continues to evolve as the health system responds to internal learning, evaluation, research, and insights from peers.
This article was adapted from the Children’s Hospital Association and Nyoo Health report, Screening for Social Drivers of Health: Children’s Hospitals Respond, that highlights strategies to address social needs and ways to integrate screening tools throughout a hospital.
