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Screening for Social Needs: Addressing More than Health Conditions

By: Danielle Maholtz, DO, FAAP and Carley Riley, MD, MPP, MHS, FAAP

A movement is underway in medicine to provide more holistic patient care that addresses not only the clinical conditions of patients but also the upstream factors that impact health of people. The World Health Organization (WHO) has defined these upstream factors as social determinants of health (SDoH), “the conditions in which people are born, grow, live, work and age” which are “shaped by the distribution of money, power and resources” (1). Since then, these conditions have been categorized into five broad categories: economic instability, education, social and community context, health and health care and neighborhood and build environment (2). Included in this list are health factors which represent things we can change to improve health for all like opportunities for quality education, access to healthy foods and secure and affordable housing. According to the Robert Wood Johnson Foundation County Health Rankings and Roadmaps, 50% of social risk factors impacting health outcomes are health factors that can be targeted to improve general population health (3).

Improving health and achieving health equity require innovation in how children with unmet needs across these social determinant categories are identified. Screening tools have been validated for identification of these unmet social needs in pediatric outpatient offices. Recognition that patients with unmet social needs frequently have difficulties with outpatient follow up has led to efforts to screen in the acute care and inpatient settings. Children requiring critical care have been recognized as being at greater risk for unmet social needs than the general population, but no work has yet utilized screening to identify unmet social needs in the pediatric critical care population.

To learn more about how these needs impact critically ill children and lead in the movement to address unmet social needs that impact child health and wellbeing, the Cincinnati Children’s Hospital Medical Center Pediatric Intensive Care Unit formed a multidisciplinary team of Pediatric Intensive Care physicians, advanced practice practitioners, nurses, and social workers. This team developed a process to screen children and their caregivers admitted to our intensive care unit for unmet social needs and then respond to identified needs. We recently received an American Academy of Pediatrics Section on Critical Care Small Project Award to support this effort. Since beginning the screening process in 2021, our unit has identified many patients with unmet social needs and connected their caregivers with hospital and community-based resources. There has been a positive response to the families involved in the process. Our future goals are to standardize and implement this screening process for all children admitted to our unit and to collaborate with the acute care and outpatient office teams to overlap our screening process with those already existent in other areas of the medical system.


1. Alderwick, H. and L.M. Gottlieb, Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems. Milbank Q, 2019. 97(2): p. 407-419.
2. Sokol, R., et al., Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics, 2019. 144(4).3.
3. “2020 County Health Rankings Key Findings Report.” County Health Rankings & Roadmaps,
Screening For Social Needs: Addressing More Than Health Conditions
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