Expanding implementation of a social determinants of health screening and referral program to community-based pediatric clinics

Objective: Social determinants of health (SDOH) are nonmedical factors that impact health and well-being. Primary care clinics have implemented screening for SDOH, but system-wide programs that reach multiple clinics remain limited in pediatric settings. This study evaluates the system-wide implementation of a SDOH screening and resource referral program at 8 community-based pediatric primary care clinics.

Methods: The SDOH program, which is built into the electronic health record (EHR), was piloted at a large, academic-based clinic. Implementation strategies from the pilot were used in this study. Implementation was evaluated with the RE-AIM framework. Data was collected from the EHR and surveys of the clinic practice managers.

Results: During the implementation phase (07/01/23-12/31/23), all 8 community-based clinics supported adoption of the program. Five clinics identified champions, and 4 completed training and adopted quality assurance processes. During the maintenance phase (01/01/24-09/30/24), there were 14590 well child visits across all clinics, and 9818 (67.3%) completed screening. SDOH screening rates varied between clinics (21.6% – 95.9%). Clinics tended to maintain their screening rates over time. 2542 patient caregivers (25.9%) who completed screening were positive for at least one SDOH domain. Most clinics reported using a combination of resource lists (78%) or referrals (89%) to address positive screens. 67% of clinics reported the screening took less than 5 minutes per patient and addressing positive screens took 5 minutes or less.

Conclusions: The EHR-based SDOH screening and resource referral program was effectively expanded to multiple community-based pediatric primary care clinics, and screening rates were maintained over time.