Background: Equitable healthcare outcomes are compromised in the absence of strong medical care and social services linkages. In May 2019, Children’s Health, the largest health system for pediatric care in North Texas, initiated a three-pronged social determinants of health (SDOH) quality improvement (QI) project that included: 1) baseline and ongoing clinical team training; 2) implementation of an electronic health record (EHR)-embedded SDOH screening tool; and 3) patient referrals to community resources in three inpatient hospital units and one outpatient specialty clinic serving medically complex patients. The purpose of the study is to identify hospital unit/clinic-level implementation factors associated with effective utilization of a SDOH screening tool newly introduced into the clinical setting and outcomes associated with this screening such as referrals to community-based organizations.

Methods: A mixed-methods, descriptive study was conducted in the following four pediatric care settings: (1) intensive care unit (PICU); (2) acute, long-term hospitalized patients (LTP); (3) inpatient multi-specialty step-down facility serving patients with special healthcare needs (SHCN); and (4) cystic fibrosis clinic (CF). Quantitative measurement tools (i.e. clinical care team pre/post surveys, EHR data) were merged with focus groups to elucidate factors influencing implementation. The Consolidated Framework of Implementation Research guided assessment.

Results: Of the 506 eligible patients, SDOH screening rates (PICU=42%; CF=76%; LTP=85%; SHCN=93%) and referral to community resources rates (PICU=20%; CF=46%; SHCN=52%; LTP=91%) significantly differed across the various hospital units. Among the clinical care team surveys, PICU clinical team members reported significantly lower baseline confidence to discuss SDOH (mean=2.93; SD=0.95) and significantly lower knowledge of SDOH (mean=2.66; SD= 0.88) compared to the three other clinics. Qualitative data indicated that all hospital units prioritized the intervention, had clinical champions, and used thoughtful planning. Screening and referral rate differences were attributed to several factors; (1) settings (e.g., inpatient vs. outpatient setting, resistance to change); (2) individual characteristics (e.g., self-efficacy, baseline confidence, licensure of implementer); and (3) intervention characteristics (e.g. adaptability, compatibility).

Conclusions: Results suggest that the successful implementation of a SDOH screener in pediatric health care settings serving medically complex patients is a multifaceted process involving multilevel factors. These findings can guide feasibility of further dissemination and scalability efforts in particular.

Key Take Away Points

-Health-related social needs are high among medically complex pediatric patients and their families

-Successful screening for social determinants of health is highly dependent on the hospital unit in which it's implemented

-Health systems need patient navigators to follow-up with patients regarding their health-related social needs and to actively connect them to community-based organizations

Author Biography

KKJ is a social epidemiologist and Assistant Professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences at the University of Texas Health Science Center, School of Public Health (UTSPH) and member of the Center for Pediatric Population Health in Dallas. PR is a pediatrician, Vice President and Chief Health Equity and Inclusion Officer at Children’s Health and active member at CPPH. OKO is a scientist within the Health Equity team at Children’s Health. MSM is the Data Manager at the CPPH. SS is a practicing lawyer at the Legal Aid of NorthWest Texas. UB-N is a candidate for the Masters of Public Health program at UTSPH. SEM is a Professor at UTSPH and Director of CPPH.


We would like to thank all of the clinical care team members that implemented and championed this effort. Without your enthusiasm and success, we could not effectively address social needs for our patients.