Social Determinants of Health Resources

Action Learning Collaborative

Developed by the National Resource Center for Patient/Family-Centered Medical Home, the Action Learning Collaborative (ALC) was a 8-month quality improvement project, highlighting collaborations between state agencies and clinical practices. The goal of the ALC was for teams to work collaboratively to advance patient/family-centered medical home by strengthening state partnerships; increasing screenings for social determinants of health (SDoH); increasing referrals and linkages to local and community resources after positive screenings for SDoH are identified; identifying protective factors for social/emotional health in partnership with families; and increasing access to a patient/family-centered medical home. Tools and resources developed for the ALC are available below.

• ​Change Pa​ckage
  This interactive change package lists countless resources to support SDoH implementation at the clinical, community, and state level. Each resource listed in the Excel page is hyperlinked and free to access or download.
• Educational​ Webinars​
  During the action period of the project, faculty presented on various topics related to SDoH screening, referral, and follow up. Virtual presentations are available to download.
  • Working with Diverse Families
  • Sustainability and Scalability
  • Documentation, Referral, and Follow Up​

Education Series

The National Resource Center for Patient/Family-Centered Medical Home (NRC-PFCMH), in partnership with Bright Futures National Center and the Screening Technical Assistance and Resource (STAR) Center, implemented an educational webinar series, Making Connections: The Critical Role of Family-Centered Care in Addressing Social Determinants of Health​ for Children and Youth with Special Health Care Needs (CYSHCN).

The goal of this 2-part webinar ​series was to pr​ovide state Title V Maternal and Child Health (MCH) / CYSHCN programs, pediatricians, families, and others with information about the impact of social determinants of health on CYSHCN and their families, including implementation strategies for state programs. The series discussed the role of these groups and state systems in addressing SDOH for CYSHCN by using components of the medical home model.

The first webinar in this series will provided relevant​ background information about how CYSHCN are impacted by SDOH, including a review of current data. The second webinar featured 2 state Ti​tle V MCH / CYSHCN programs who will discuss how their states are addressing SDOH for CYSHCN.

• Episode 1
  • ​Listen on Youtube​
  • ​View PowerPoint Slides
  • Q&A Document​
• Episode 2
  • ​Listen on Youtube
  • ​View PowerPoint Slides
  • Q&A Document​​​
• Resources List

Fact Sheets

Developed by the National Resource Center for Patient/Family-Centered Medical Home, in partnership with the National Academy for State Health Policy, this fact sheet series discusses​ social determinants of health (SDoH) screening and referrals for children and youth with special health care needs (CYSHCN) and their families. Opportunities for collaboration and partnership between Medicaid, Title V Maternal and Child Health / CYSHCN programs, and pediatricians are discussed. State-level case studies provide innovative and replicable strategies for implementing SDoH screening and community referrals.

• Identification and Screening of Social Determinants of Health Among Children with Special Health Care Needs in Medicaid ​
• Social Determinants of Health Referrals in Medicaid and the Role of Medicaid Managed Care Contracts ​​​
• Implementing Medical Homes for Children and Youth with Special Health Care Needs within Medicaid Managed Care ​​​​​

Visit the Screening and Tech​​​ni​cal Assistance Resource (STAR) Center for more tools, resources, and recommendations for SDoH screening, referral, and follow up.

Family Resources

• ​​​​Social Determinants of Health Information Flyer for Families
  The National Resource Center for Patient/Family-Centered Medical Home released a supplemental social determinants of health flyer for the American Academy of Pediatrics and the Food Research & Action Center recently updated screening toolkit, Screen & Intervene: A Toolkit for Pediatricians to Address Food Insecurity. The flyer is available in English (8 ½ x 11 or 11 x 14) and Spanish (8 ½ x 11 or 11 x 14) and can be posted in pediatric clinics and practices to support families of children and youth with special health care needs and children with disabilities to increase their awareness of their pediatricians' role in supporting their non-medical needs, such as food insecurity, housing, transportation, and mental health. ​​​
• HealthyChildren.org article
  The National Resource Center for Patient/Family-Centered Medical Home (NRC-PFCMH) has partnered with Dr Joan Jeung, Executive Committee member of the American Academy of Pediatrics' (AAP) Section on Minority Health Equity and Inclusion (MHEI) and NRC-PFCMH Advisory Committee member, to write an ar​ti​cle​ addressing social determinants of health (SDoH) ​screening for families with children and youth with special health care needs (CYSHCN). This article focuses on the role of the pediatrician in supporting families with non-medical concerns, such as meeting basic needs, dealing with stress and emotional concerns, in addition to highlighting support services available for families.