Identifying and Addressing Unmet Social Needs in a Pediatric Rehabilitation Hospital

Health care leaders and clinicians have long recognized the connection between unmet social determinant of health needs such as food, housing and transportation, and health outcomes. As a component of broader organizational efforts to improve equitable access to services, we introduced a Social Needs Screening (SNS) Initiative in 2020 in our pediatric rehab hospital context.Implementation: This presentation describes the systematic approach taken across the components of the SNS initiative:

1. Identification and implementation of an evidence-based SNS Tool (Health Leads 2018),

2. Creation of internal ‘action pathways’ to support social needs,

3. Launch of a Family Navigation Hub (FNH) providing navigation interventions,

4. Fostering of personalized linkages to resources and services to address social needs.

We describe implementation and change management approaches used to integrate SNS into interprofessional team workflows and outline guiding principles that support a social needs navigation service within a hospital setting.Evaluation plan: The presentation highlights evaluation results (April 2020 - present) illustrating the nature and frequency of significant social needs that families face everyday. We will outline the design and structure of the FNH at Holland Bloorview - a service for families who self-identify unmet needs through a interprofessional clinician-delivered social needs screening process, and will provide evaluation data related to the experience of families who were referred to, and received services in, the FNH.Outcome(s) and significance: This presentation calls attention to the importance of actively shifting from traditional to equity-oriented approaches which serve to strengthen family and community health, as demonstrated through key components of this service including:

• The use of trauma-informed, strength-based approaches and navigation tools in co-creating action pathways

• The impact of personalized linkages between families and community resources

• Community partnership-building, stakeholder engagement and responsiveness to emergent needs

• Developing interprofessional capacity related to unmet social needs of families seeking rehabilitation services.