Holland Bloorview Kids Rehabilitation Hospital embarked on a review of the Collaborative Practice & Clinical Education Model that has been in place for over 15 years. Through targeted focus groups, environmental scan, and literature review, four themes and recommendations for model optimization were found.

As a component of broader organizational efforts to improve equitable access to services, we introduced a Social Needs Screening (SNS) Initiative and a Family Navigation Hub in 2020. The Family Navigation Hub aims to address unmet social needs in a systematic, evidence-informed way. The model aims to: 1. IDENTIFY: Identify unmet social needs related to food security, housing stability, child care, transportation, utilities, health care costs, health literacy and supportive community connections through the use of an evidence based screening tool (adapted internally for our pediatric setting), 2. CONNECT: Enhancing our relationships with community partners to better support social needs (e.g., a series of CommunityCONNECT workshops which we co-deliver with a community agency), 3. ADDRESS: Creation of internal ‘action pathways’ to support unmet social needs, including referrals for individualized support in the Family Navigation Hub where we provide navigation interventions and warm handovers with community partners, 4. LINK: Fostering of personalized linkages to resources and services to address unmet social needs. This systematic approach to screening for social needs ensures all families are equitably offered the opportunity to share challenges that could otherwise interfere with their ability to fully participate in, and benefit from the care and services they receive.