OBJECTIVES

To assess the implementation and effectiveness of the augmented WE CARE social care system on low-income children’s health care utilization and child maltreatment outcomes.

METHODS

We conducted a type 1 hybrid effectiveness-implementation cluster randomized controlled trial at 6 community health centers. Full-term infants were followed from birth to age 3. The 3 experimental clinics implemented the augmented WE CARE system at well-child visits, consisting of a self-report screening instrument for 7 basic needs; an electronic health record-generated resource information referral system; and access to a peer patient navigator. Families at control community health centers received usual care; 1 control site was contaminated and removed from primary analysis. We analyzed results using generalized mixed-effects models.

RESULTS

Overall, 878 children were followed until age 3. Implementation of WE CARE was poor with only 28.9% of visits having a WE CARE screener documented. WE CARE families received significantly more resource referrals than control families (43.1% vs 1.9%, adjusted odds ratio 4.6; 95% confidence interval, 2.0–5.6); 20% were referred to the patient navigator. WE CARE children had significantly higher immunization adherence ratios. Although there were no statistically significant differences with well-child visits, WE CARE children had higher rates of emergency department visits than control children. By age 3, WE CARE children had significantly higher hospitalization rates (14.1% vs 10.4%, adjusted odds ratio 1.3, 95% confidence interval: 1.03–1.7). There were no statistically significant differences with maltreatment outcomes.

CONCLUSIONS

We found poor implementation and mixed benefits for the augmented WE CARE system on immunization, health care utilization, and maltreatment outcomes in early childhood.

What’s Known on This Subject:

Although social care screening and referral systems are rapidly being implemented into pediatric practice, little is known regarding their implementation in real-world settings, potential beneficial impact on improving children’s health care utilization patterns, child maltreatment outcomes, and/or unintended consequences.

What This Study Adds:

This study demonstrates that although the implementation of a social care system led to increased referrals for families’ unmet needs and improved immunization adherence, overall, it had mixed beneficial impact on health care utilization and maltreatment outcomes in early childhood.

In 2016, the American Academy of Pediatrics (AAP) formally recommended pediatric clinicians screen for social risk factors at visits.1  This guideline, along with ensuing Medicaid and child health policies,2,3  has transformed pediatric practice such that screening for social risks and/or social needs via standardized tools at well-child visits is rapidly becoming standard of care.

Yet, there are limited studies examining the implementation of social care screening and referral systems in real-world settings as well as the evidence for their potential beneficial impact on improving children’s health care utilization patterns and/or their unintended consequences.47  Since 2004, our team has been continually developing, modifying, implementing, and evaluating WE CARE—a social care system wherein parents complete a written, self-administered social risk and need screener at visits and clinicians provide need-specific resource information referrals for domains with which parents request help.8,9  Our prior randomized controlled trial (RCT) demonstrated the efficacy of WE CARE on increasing pediatricians’ referrals and low-income families’ receipt of new resources and benefits at community health centers (CHCs) under controlled conditions.9  The objective of this study was to assess the implementation and effectiveness of the augmented WE CARE social care system under real-world conditions on health care utilization and child maltreatment outcomes among low-income children in early childhood.

We conducted a type 1 hybrid effectiveness-implementation cluster RCT in CHCs located within a 3-mile radius in Boston, Massachusetts from September 2015 to March 2020. CHCs were randomized 1:1 to either the augmented WE CARE or control group. Group assignment was concealed until a practice agreed to participate in the study. Each CHC provided care to ∼90 to 250 newborns annually (mean = 180).

All parent-child dyads who presented for a newborn visit to participating CHCs between September 2015 and March 2017 were eligible. Since our study population included healthy low-income children insured by Medicaid at baseline, families were excluded if the newborn had a history of prematurity (ie, born before 32 weeks), had commercial insurance, or was born with a chronic disease (eg, cardiac disease) or with Neonatal Abstinence Syndrome. Newborns living with foster parents were also excluded.

Augmented WE CARE Arm

The augmented WE CARE system was implemented in the experimental arm CHCs as standard of care at well-child visits from birth to age 3. Research staff trained the clinical staff during a 1-hour session and with five 30-minute booster sessions over the study period. The augmented intervention consisted of 3 core components: (1) WE CARE screening instrument; (2) community resource information sheets made available from the electronic health records (EHR); and (3) a peer patient navigator.

CHC staff were trained to provide each family who came in for a well-child visit until at least age 3 with a WE CARE screening instrument at check-in. Overall, the instrument consisted of 14 questions designed to identify 7 social risks and determine families’ desire for assistance with: child care, education (parent not completing high school), employment, food security, household heat, housing, and language (eg, need for ESL classes) (Supplemental Appendix). The screener was written at third-grade level, made available in English, Spanish, and Vietnamese, and took <5 minutes to complete. Of note, the original screening instrument that this tool was adapted from has a test-retest reliability of 0.92.8  The WE CARE screener was consistent with the prior tool except that language need was added based on clinicians’ and CHC staffs’ recommendations.

Pediatric health care team members were able to access resource sheets initially on an external website embedded in Centricity EHR. These sheets listed a maximum of 4 community resources and included program name, contact information, program hours, and eligibility criteria for each specific need. A telephone number was listed at the bottom of each sheet that families could call to contact a patient navigator for assistance. The resource sheets were updated every 3 months.

Approximately 9 to 18 months after the study began, all the CHCs switched to Epic© EHR. Smart phrases were created in Epic© to disseminate resource information. Health care team members were trained to type smart phrases into the After Visit Summary, which auto populated community resource information, which they then provided to parents with needs. The resource information contained in the original resource information sheets and the After Visit Summary were written at, or below, fifth-grade reading level and available in English or Spanish.

A peer patient navigator was made available to meet with families, inquire about needs, and assist families with completing applications. The navigator was on site at least 1 day per week per site and received referrals from staff and clinicians via warm handoffs or messaging within the EHR. She contacted families to support and guide them in receiving community-based resources and entered notes into the EHR regarding families’ connecting with and accessing resources.

Of note, the funding mechanism (RFA-MD-12-003) called for integration of new technology and peer navigation; thus, the augmented WE CARE system differed from the original tested WE CARE system9  by offering resource sheets from the EHR (versus a Family Resource Book) and by including a peer patient navigator (versus research staff).

Control Arm

Participants at control CHCs received usual care. In order to compare referrals as well as for ethical reasons, the same resource information sheet referral system was embedded into control CHCs’ EHR (first in Centricity and then in Epic©). The pediatric team was notified of this by the research team at the study’s start and during the EHR transition.

Data were extracted post hoc through EHR review for visits during the study period (September 2015 to March 2020). Research staff reviewed each eligible participant’s chart for all visits from the newborn visit to the 3-year-old well-child visit. Staff collected sociodemographic data and data on documentation of resource information sheet printouts (consistent with our prior study, we use the term “referral” moving forward), child maltreatment, child protective services reports (CPS), and health care utilization outcomes. In the experimental arm, data on WE CARE screeners scanned into the EHR were recorded for each visit. Families referred to the patient navigator were logged into an Excel spreadsheet and crosschecked with the child’s EHR. For 10% of the charts, we had another research staff review the data; overall, there was strong concordance with an error rate of 0.12%. All discrepancies were resolved with the first author (A.G.). Data were censored at control sites if they began implementing a social needs and risk screener or at WE CARE sites if they began using a different screening instrument.

The primary study outcomes were measures of health care utilization, including emergency department (ED) visits, hospitalizations, and adherence to the AAP’s well-child visit and immunizations schedules. Secondary outcomes included referrals to resources and/or the patient navigator. We also examined EHR-documented reports to CPS and of children with suspected maltreatment. To evaluate experimental sites’ implementation of WE CARE, we calculated the percentage of visits with a WE CARE screener scanned into the EHR, as well as percentage of appropriate referrals (defined as information sheet printed out for parent indicating they want help on the screener).

Before conducting the study, we estimated a total of 8 CHCs would participate. We modeled our participation rate based on prior pediatric CHC data. Assuming an intraclass correlation of 0.02, we expected to have over 80% power to detect a 5% difference in our health care utilization, maltreatment, and referral outcomes.

Descriptive statistics were conducted on sociodemographic characteristics, screener administration, referrals, and outcome variables cumulatively over the 3-year time period as well as per year. Consistent with Abdus’ and Selden’s methodology,10,11  we created well-child visit and immunization adherence ratios by dividing the number of visits attended and immunizations received by the overall numbers of well-child visits and immunizations recommended by the AAP for ages 0 to 1 year, >1 to 2 years, and >2 to 3 years of age.

Since 1 control site began implementing a similar social care system within the first year of the study, we considered them contaminated and excluded them from our primary analyses. For cumulative effects that were statistically significant, we also used an intention-to-treat approach and included the contaminated control site to compare augmented WE CARE and control groups. Generalized mixed-effects models were used to estimate the differences in sociodemographics between groups as well as test direct intervention effects on outcomes adjusting for time, CHC intraclass correlations, and sociodemographics. A random intercept for each site was included in the model to account for within-site correlation.

All statistical analyses were performed using the SAS software version 9.4 (SAS Institute, Inc, Cary, NC). Adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values were calculated for each model. Statistical significance was defined as P < .05.

The Boston University Medical Center Institutional Review Board approved this study. The study was registered on clinicaltrials.gov (NCT02451059) before its onset.

Eight CHCs in the Boston HealthNet network were initially approached to participate in the study; 2 CHCs declined because of lack of interest and anticipated burden, resulting in a total of 6 participating sites (n = 1193 patients). Although the initial data pull of potentially eligible records included 1485 newborns, 292 were excluded upon further review because of insurance status, chronic disease status, and duplication of records. Our final cohort included 3 sites in the WE CARE arm (n = 524 patients) and 3 in the control arm (n = 669 patients). Within a few months of implementation, as noted above, a control site (n = 315 patients) began their own social care screening and referral system and was therefore contaminated (Fig 1).

FIGURE 1

Flow of community health center clusters and participants in the WE CARE effectiveness-implementation trial.

FIGURE 1

Flow of community health center clusters and participants in the WE CARE effectiveness-implementation trial.

Close modal

At baseline each CHC already had social history probing questions (eg, child care, housing, school) embedded in their well-child visit templates. Also, all CHCs had social workers, case managers, and/or volunteers to assist families with basic needs.

Among our cohort of children, a slight majority were female, almost half were non-Hispanic Black, and over a quarter were Latino/a/e. The most common household language was English (67.0%), followed by Spanish (12.6%), and Vietnamese (8.2%) (Table 1).

TABLE 1

Baseline Child Participant Characteristics

 Total (N = 878) WE CARE (n = 524) Control (n = 354) 
Sex, n (%)    
 Female 462 (52.6) 271 (51.7) 191 (54.0) 
 Male 416 (47.4) 253 (48.3) 163 (46.0) 
Race and ethnicity, n (%)    
 Asiana 95 (10.8) 91 (17.4) 4 (1.1) 
 Black or African Americana 374 (42.6) 207 (39.5) 167 (47.2) 
 Latino/a/e 239 (27.2) 106 (20.2) 133 (37.6) 
 Whitea 44 (5.0) 37 (7.1) 7 (2.0) 
 Othera 102 (11.6) 63 (12.0) 39 (11.0) 
Household language, n (%)    
 English 588 (67.0) 328 (62.6) 260 (73.4) 
 Haitian Creole 49 (5.6) 9 (1.7) 40 (11.3) 
 Spanish 111 (12.6) 56 (10.7) 54 (15.3) 
 Vietnamese 72 (8.2) 72 (13.7) 
 Other 58 (6.6) 59 (11.3) 
 Total (N = 878) WE CARE (n = 524) Control (n = 354) 
Sex, n (%)    
 Female 462 (52.6) 271 (51.7) 191 (54.0) 
 Male 416 (47.4) 253 (48.3) 163 (46.0) 
Race and ethnicity, n (%)    
 Asiana 95 (10.8) 91 (17.4) 4 (1.1) 
 Black or African Americana 374 (42.6) 207 (39.5) 167 (47.2) 
 Latino/a/e 239 (27.2) 106 (20.2) 133 (37.6) 
 Whitea 44 (5.0) 37 (7.1) 7 (2.0) 
 Othera 102 (11.6) 63 (12.0) 39 (11.0) 
Household language, n (%)    
 English 588 (67.0) 328 (62.6) 260 (73.4) 
 Haitian Creole 49 (5.6) 9 (1.7) 40 (11.3) 
 Spanish 111 (12.6) 56 (10.7) 54 (15.3) 
 Vietnamese 72 (8.2) 72 (13.7) 
 Other 58 (6.6) 59 (11.3) 
a

Non-Latino/a/e.

In the experimental arm, 28.9% of visits had a WE CARE screener scanned into the EHR. WE CARE screening ranged between 21.0% and 43.8% across the 3 sites. Over a third of parents who indicated wanting help with a need received an appropriate referral (38.7%, range 27.7% to 49.3%).

WE CARE families received significantly more resource referrals than control families at well-child visits (43.1% vs 1.9%; aOR 4.6; 95% CI, 2.0–5.6). The most common referral was for child care (25.8% of total referrals), followed by utilities (14.4%), and employment (14.1%). Over 20% of WE CARE families were referred to the patient navigator; the navigator connected with 73.4% of families via telephone, text message, or email.

Although WE CARE families had higher well-child visit adherence ratios, this did not achieve statistical significance. WE CARE children had significantly higher immunization ratios across all 3 years (Table 2). WE CARE children also had significantly higher ED visit rates than control children for all ages (Table 3). Although there were no significant differences in hospitalizations in the first 2 years, WE CARE children had significantly higher cumulative hospitalization rates by age 3 (14.1% vs 10.4%, aOR 1.3, 95% CI: 1.03–1.7). Results were similar in the intention to treat models as well.

TABLE 2

Well-Child Visit and Immunization Adherence Ratios (Expressed as a Percentage)

 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC P 
WCC visit adherence ratio, % (SE)      
 1 year 59.7 (0.2) 56.4 (0.2) 0.04 0.02 .1 
 2 year 48.8 (0.1) 45.5 (0.1) 0.04 0.03 .1 
 3 year 40.9 (0.1) 38.4 (0.1) 0.04 0.02 .1 
Immunization adherence ratio, % (SE)      
 1 year 43.8 (0.2) 40.8 (0.2) 0.02 0.01 .03 
 2 year 83.5 (0.3) 78.9 (0.4) 0.02 0.005 .04 
 3 year 85.6 (0.3) 80.3 (0.4) 0.01 <0.0001 .003 
 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC P 
WCC visit adherence ratio, % (SE)      
 1 year 59.7 (0.2) 56.4 (0.2) 0.04 0.02 .1 
 2 year 48.8 (0.1) 45.5 (0.1) 0.04 0.03 .1 
 3 year 40.9 (0.1) 38.4 (0.1) 0.04 0.02 .1 
Immunization adherence ratio, % (SE)      
 1 year 43.8 (0.2) 40.8 (0.2) 0.02 0.01 .03 
 2 year 83.5 (0.3) 78.9 (0.4) 0.02 0.005 .04 
 3 year 85.6 (0.3) 80.3 (0.4) 0.01 <0.0001 .003 

Adjusted for child race and ethnicity, household language, and child gender. ICC, intraclass correlation; WCC, well-child care.

TABLE 3

Emergency Department Visits and Hospitalizations

 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC aOR (95% CI) 
ED visits, n (%)      
 1 year 244 (46.4) 116 (32.8) 0.03 <0.0001 2.2 (1.7–2.8) 
 2 year 329 (62.5) 158 (44.6) 0.04 <0.0001 2.7 (2.1–3.4) 
 3 year 361 (68.6) 187 (52.8) 0.04 <0.0001 2.4 (2.0–2.9) 
Hospitalizations, n (%)      
 1 year 43 (8.2) 24 (6.8) <0.0001 <0.0001 1.1 (0.9–1.5) 
 2 year 61 (11.6) 33 (9.3) 0.006 <0.0001 1.2 (0.8–1.6) 
 3 year 74 (14.1) 37 (10.4) 0.007 <0.0001 1.3 (1.03–1.7) 
 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC aOR (95% CI) 
ED visits, n (%)      
 1 year 244 (46.4) 116 (32.8) 0.03 <0.0001 2.2 (1.7–2.8) 
 2 year 329 (62.5) 158 (44.6) 0.04 <0.0001 2.7 (2.1–3.4) 
 3 year 361 (68.6) 187 (52.8) 0.04 <0.0001 2.4 (2.0–2.9) 
Hospitalizations, n (%)      
 1 year 43 (8.2) 24 (6.8) <0.0001 <0.0001 1.1 (0.9–1.5) 
 2 year 61 (11.6) 33 (9.3) 0.006 <0.0001 1.2 (0.8–1.6) 
 3 year 74 (14.1) 37 (10.4) 0.007 <0.0001 1.3 (1.03–1.7) 

Adjusted for child race and ethnicity, household language, and child gender. ICC, intraclass correlation.

There were no statistically significant differences in reported child maltreatment cases or CPS reports between the groups in the first 3 years (Table 4).

TABLE 4

Documentation of Child Abuse and Child Protective Services Reports in the EHR

 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC aOR (95% CI) 
Child abuse documentation, n (%)      
 1 year 4 (0.8) 8 (2.3) 0.04 0.06 0.4 (0.07–1.9) 
 2 year 10 (1.9) 12 (3.4) 0.1 0.2 0.4 (0.04–4.5) 
 3 year 22 (4.2) 18 (5.1) 0.2 0.2 0.5 (0.06–3.7) 
Families with at least 1 CPS report, n (%)      
 1 year 37 (7.0) 32 (9.0) 0.01 0.03 0.8 (0.3–1.8) 
 2 year 59 (11.2) 51 (14.4) 0.003 0.006 0.9 (0.5–1.4) 
 3 year 79 (15.0) 72 (20.3) 0.03 0.03 0.7 (0.4–1.3) 
 WE CARE (n = 524) Control (n = 354) ICC Adjusted ICC aOR (95% CI) 
Child abuse documentation, n (%)      
 1 year 4 (0.8) 8 (2.3) 0.04 0.06 0.4 (0.07–1.9) 
 2 year 10 (1.9) 12 (3.4) 0.1 0.2 0.4 (0.04–4.5) 
 3 year 22 (4.2) 18 (5.1) 0.2 0.2 0.5 (0.06–3.7) 
Families with at least 1 CPS report, n (%)      
 1 year 37 (7.0) 32 (9.0) 0.01 0.03 0.8 (0.3–1.8) 
 2 year 59 (11.2) 51 (14.4) 0.003 0.006 0.9 (0.5–1.4) 
 3 year 79 (15.0) 72 (20.3) 0.03 0.03 0.7 (0.4–1.3) 

ICC, intraclass correlation; CPS, child protective services.

We found that a social care screening and referral system implemented in pediatric primary care was not only challenging to implement and maintain, as evidenced by infrequent screening and appropriately made referrals, but also had varied impact on immunization, health care utilization, and maltreatment outcomes. Although WE CARE children had higher immunization adherence ratios (and trends for higher well-child visit adherence), paradoxically they also had higher ED visits and hospitalization rates by age 3. To our knowledge, our study is the first clinical trial assessing the implementation and effectiveness of social care systems implemented in real-world primary care conditions, and thus our results carry important clinical and policy implications.

This 5-year study was a pragmatic trial conducted during a backdrop of unanticipated seismic changes in social care policies and recommendations. Begun 1 year before the AAP’s policy statement on Child Poverty recommending pediatricians screen for social factors and ending days before the coronavirus disease 2019 pandemic started, multiple social care initiatives including the Accountable Health Communities Model,3  Medicaid policies,2,12  and professional recommendations, including from the National Academy of Sciences, Engineering, and Medicine,4  were enacted that accelerated the practice of screening and referring for unmet basic needs into pediatrics as standard of care (including in 1 of our control CHCs early in 2016 and many of our CHCs by the end of the study). Yet, despite this rush to implementation, there is limited evidence about the impact that these models have on children’s health and health care, along with its unintended consequences.7  Our results, which will be harder to replicate in pediatric practices given the current social care landscape, should give policy makers, health system leaders, and clinicians pause in their rush to implement and maintain screening for social drivers.

With our focus on the effectiveness component of this type 1 hybrid effectiveness-implementation study,13  we purposefully did not provide feedback regarding implementation metrics to practices in real-time, which in hindsight was a critical mistake. Compared to our efficacy study,9  our referral rate of 43% over a course of multiple visits for children in the first 3 years of life was much lower than our rate of 70% found at 1 index well-child visit, despite both studies being conducted in the same and/or similar CHCs. Qualitative work with staff and clinicians found strong mission alignment with the augmented WE CARE system, belief that it benefited their patients, and was overall easy to implement.14  However, the low rates of documented screening and appropriate referrals indicate poor implementation and highlight the importance of identifying and addressing organizational and administrative barriers before rolling out social care systems. Having clinical champions, piloting workflows, getting buy-in from all involved staff, sharing success stories, and monitoring and sharing back implementation data using quality improvement techniques and evolving workflows are likely critical in fully integrating social care into pediatric primary care.15 

Beyond poor implementation, there are likely other factors that led to our unexpected results. Because of funding, we only had 1 patient navigator serving 3 clinics, which limited her on-site presence. We previously reported that clinicians were more likely to refer families if the navigator was on site.16  Although we found trends with well-child visit adherence and directionality for lower maltreatment outcomes for WE CARE children, none of these results achieved statistical significance. Prior investigators testing the SEEK model, which includes addressing poverty-related needs, found it led to lower rates of maltreatment under controlled conditions.17  Our findings may have also resulted from a loss of power because of contamination.

We are perplexed with our ED and hospitalization findings. We had expected WE CARE children to have better health outcomes based on the OASIS model, which suggests that the augmented WE CARE system can improve health care outcomes by reducing competing demands and stress for parents.18  In addition, clinical efficacy trials from Gottlieb et al have found improved parental report of child health and a reduction in hospitalizations from their similar social care intervention.1921  So why did we find the opposite? One possible explanation is that there was unmeasured confounding related to CHC-specific risk factors that were related to going to the hospital. Another possibility and/or contributing factor could be because of the negative ramifications of poor implementation, particularly related to referrals. Less than 40% of appropriate referrals were made, suggesting that the majority of time when a family indicated they wanted help with a basic need like food, there was no action taken by the health care team. This concept of double loss (ie, disclosing needs without having them addressed) can erode parents’ trust and lead to frustration22 ; perhaps it led some families to go to the ED instead of their child’s clinic when their child was ill. Alternatively, these results may be attributable to the intervention helping foster trust with the health care system; families who received WE CARE may have been more likely to go to the ED when they were sick or accept admission to the hospital. Further qualitative studies with parents and caregivers are needed.

There were limitations to the study. The study may have limited generalizability since it was conducted at CHCs. Study sites had robust support staff (eg, social workers, case managers) which may have contributed to our mixed results. Future studies should consider evaluating social care models in practices without such existing support. As previously noted, over the 5-year study period there were many pragmatic challenges, including EHR platform changes, staff turnover, and contamination. Finally, we relied primarily on the EHR documentation for our data, which may have undercounted our implementation screening outcome and conversations around social needs that might have occurred between clinicians and parents.

Overall, we found it was challenging to implement a social care screening and referral system with patient navigation in pediatric practice. Although the augmented WE CARE system led to increased referrals for families’ needs and higher immunization rates, it also led to more ED visits and hospitalizations. Further work is needed to build upon our study. Until then, caution and likely tempered expectations are necessary when developing and implementing social care policies and clinical interventions to identify and address unmet needs.

Our study found poor implementation and mixed benefits for a screening and referral social care system integrated into pediatric primary care on immunization, health care utilization, and maltreatment outcomes in early childhood.

We thank Michelle Pellicer, MPH and Marie Joseph, BA for their efforts and contributions to the study; and the patients and staff at Codman Square Health Center, DotHouse Health, Greater Roslindale Medical and Dental Center, Mattapan Community Health Center, South End Community Health Center, and Upham’s Corner Health Center for their participation.

Dr Garg conceptualized and designed the study and drafted the initial manuscript; Ms Brochier and Ms Messmer designed the data collection instruments, collected data, and conducted some preliminary analyses; Dr Tripodis oversaw and conducted all the analyses; Dr Drainoni conceptualized and oversaw the implementation component of the study; and all authors critically reviewed and revised the manuscript for important intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

This trial has been registered at clinicaltrials.gov (identifier NCT02451059).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-062376.

Deidentified participant data will be made available upon reasonable request for scientific inquiry and exploration by the first author Dr Arvin Garg.

FUNDING: Funding provided by the National Institute on Minority Health and Health Disparities, R01MD007793. Funded by the National Institutes of Health (NIH).

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

1
Council on Community Pediatrics
.
Poverty and child health in the United States
.
Pediatrics
.
2016
;
137
(
4
):
e20160339
2
Medicaid Accountable Care Organizations
.
State update
.
3
Alley
DE
,
Asomugha
CN
,
Conway
PH
,
Sanghavi
DM
.
Accountable health communities–addressing social needs through Medicare and Medicaid
.
N Engl J Med
.
2016
;
374
(
1
):
8
11
4
National Academies of Sciences, Engineering, and Medicine
;
Health and Medicine Division
;
Board on Health Care Services
;
Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health
.
Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
.
Washington, DC
:
National Academies Press
;
2019
5
Gottlieb
LM
,
Wing
H
,
Adler
NE
.
A systematic review of interventions on patients’ social and economic needs
.
Am J Prev Med
.
2017
;
53
(
5
):
719
729
6
Garg
A
,
Byhoff
E
,
Wexler
MG
.
Implementation considerations for social determinants of health screening and referral interventions
.
JAMA Netw Open
.
2020
;
3
(
3
):
e200693
7
Garg
A
,
Boynton-Jarrett
R
,
Dworkin
PH
.
Avoiding the unintended consequences of screening for social determinants of health
.
JAMA
.
2016
;
316
(
8
):
813
814
8
Garg
A
,
Butz
AM
,
Dworkin
PH
,
Lewis
RA
,
Thompson
RE
,
Serwint
JR
.
Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project
.
Pediatrics
.
2007
;
120
(
3
):
547
558
9
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT
.
Pediatrics
.
2015
;
135
(
2
):
e296
e304
10
Selden
TM
.
Compliance with well-child visit recommendations: evidence from the Medical Expenditure Panel Survey, 2000–2002
.
Pediatrics
.
2006
;
118
(
6
):
e1766
e1778
11
Abdus
S
,
Selden
TM
.
Adherence with recommended well-child visits has grown, but large gaps persist among various socioeconomic groups
.
Health Aff (Millwood)
.
2013
;
32
(
3
):
508
515
12
Garg
A
,
Homer
CJ
,
Dworkin
PH
.
Addressing social determinants of health: challenges and opportunities in a value-based model
.
Pediatrics
.
2019
;
143
(
4
):
e20182355
13
Curran
GM
,
Bauer
M
,
Mittman
B
,
Pyne
JM
,
Stetler
C
.
Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact
.
Med Care
.
2012
;
50
(
3
):
217
226
14
Herrera
CN
,
Brochier
A
,
Pellicer
M
,
Garg
A
,
Drainoni
ML
.
Implementing social determinants of health screening at community health centers: clinician and staff perspectives
.
J Prim Care Community Health
.
2019
;
10
:
2150132719887260
15
Byhoff
E
,
Garg
A
,
Pellicer
M
, et al
.
Provider and staff feedback on screening for social and behavioral determinants of health for pediatric patients
.
J Am Board Fam Med
.
2019
;
32
(
3
):
297
306
16
Messmer
E
,
Brochier
A
,
Joseph
M
,
Tripodis
Y
,
Garg
A
.
Impact of an on-site versus remote patient navigator on pediatricians’ referrals and families’ receipt of resources for unmet social needs
.
J Prim Care Community Health
.
2020
;
11
:
2150132720924252
17
Dubowitz
H
.
The Safe Environment for Every Kid (SEEK) Model: helping promote children’s health, development, and safety: SEEK offers a practical model for enhancing pediatric primary care
.
Child Abuse Negl
.
2014
;
38
(
11
):
1725
1733
18
Gurewich
D
,
Garg
A
,
Kressin
NR
.
Addressing social determinants of health within healthcare delivery systems: a framework to ground and inform health outcomes
.
J Gen Intern Med
.
2020
;
35
(
5
):
1571
1575
19
Gottlieb
LM
,
Hessler
D
,
Long
D
, et al
.
Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial
.
JAMA Pediatr
.
2016
;
170
(
11
):
e162521
20
Gottlieb
LM
,
Adler
NE
,
Wing
H
, et al
.
Effects of in-person assistance vs personalized written resources about social services on household social risks and child and caregiver health: a randomized clinical trial
.
JAMA Netw Open
.
2020
;
3
(
3
):
e200701
21
Pantell
MS
,
Hessler
D
,
Wing
H
, et al
.
Association of 2 social needs interventions with child emergency department use and hospitalizations: a secondary analysis of a randomized clinical trial
.
JAMA Pediatr
.
2022
;
176
(
7
):
716
717
22
Schleifer
D
,
Diep
A
,
Grisham
K
.
It’s about trust: parents’ perspectives on pediatricians screening for social needs
.

Supplementary data