Burlington Pediatrics/ Mebane Pediatrics presents the interdisciplinary efforts, including tools and workflows, to implement universal screening for social determinants of health (SDOH) at an independent pediatric primary care practice. The synergies of an integrated, whole-person care model—including integrated behavioral health, care management, and nutrition—are highlighted in the presentation and discussion.

Social determinants of health (SDOH)—the social, economic, and environmental conditions in which children are born, grow, learn, and live—are recognized as primary drivers of health outcomes, health equity, and healthcare utilization across the life course (1,2). In pediatrics, unmet social needs such as food insecurity, housing instability, transportation barriers, and caregiver financial stress are strongly associated with poorer physical health, adverse developmental and behavioral outcomes, and reduced access to preventive and specialty care (3–5). These risks disproportionately affect children from historically marginalized communities, contributing to persistent health disparities (1,6).

The American Academy of Pediatrics (AAP) recommends integrating screening for social needs into routine pediatric care and emphasizes the responsibility of pediatric practices to address poverty-related risks through family-centered, community-informed approaches (6,10). Evidence supports pairing standardized screening tools with team-based response strategies—including care coordination, behavioral health integration, nutrition services, and community resource referral—to translate identification into meaningful support (8,11). The National Academies of Sciences, Engineering, and Medicine further outline a framework for integrating social care into healthcare delivery, emphasizing activities such as awareness (screening), assistance, and alignment with community resources to improve outcomes and promote equity (9).

Despite growing consensus on the importance of SDOH screening, implementation challenges remain. Systematic reviews highlight variability in screening tools, referral pathways, and outcome measurement, underscoring the need for pragmatic, real-world models that are feasible for independent practices and adaptable to local community resources (7,11). Pediatric primary care is uniquely positioned to address these challenges due to its longitudinal relationships with families, emphasis on prevention, and interdisciplinary care teams (10,12).

This presentation describes how an independent pediatric primary care practice operationalized universal SDOH screening within a whole-person care infrastructure. Key elements include workflow design, interdisciplinary roles, integration with behavioral health and nutrition services, and closed-loop referral processes. Lessons learned will inform scalable strategies for advancing equitable, sustainable SDOH screening in pediatric primary care.

References

1. World Health Organization. Social determinants of health. WHO; 2010.
2. Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Rep. 2014;129(Suppl 2):19–31.
3. Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.
4. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits. Pediatrics. 2015;135(2):e296–e304.
5. Halfon N, Larson K, Russ S. Why social determinants? Health Serv Res. 2010;45(5 Pt 2):1235–1249.
6. American Academy of Pediatrics. Screening for social determinants of health. Policy Statement; 2022.
7. Alderwick H, Gottlieb LM. Social determinants of health in healthcare systems. Milbank Q. 2019;97(2):407–419.
8. Garg A, Boynton-Jarrett R, Dworkin PH. Avoiding unintended consequences of SDOH screening. JAMA. 2016;316(8):813–814.
9. National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care. 2019.
10. Council on Community Pediatrics. Poverty, food insecurity, and homelessness. Pediatrics. 2015;136(5):e1431–e1438.
11. Eder M, Henninger M, Durbin S, et al. Screening and Interventions for Social Risk Factors. AHRQ; 2021.
12. Szilagyi M, Halfon N. Pediatric care for children in poverty. Acad Pediatr. 2015;15(3):321–329.

Identify evidence-based rationale supporting the importance of routine, universal SDOH screening in the primary care setting.

Define three defined strategies to support clinical workflows and reduce clinic barriers to SDOH screening.

Describe how an integrated care model potentiates universal SDOH screening processes.