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Social Risk Screening & Referral Addresses the High Burden of Unmet Needs Among NICU Families

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(Boston)—Poverty and adverse social determinants of health, namely unmet social needs, have well established detrimental effects on the health and development of children and the health and well-being of their caregivers. While social risk screening is recommended by the American Academy of Pediatrics, this practice is underutilized in neonatal intensive care units (NICU). The prolonged NICU hospitalization offers a unique opportunity to identify and address unmet social needs among low-income families of hospitalized newborns.

“There is a lack of knowledge on whether it is feasible and acceptable to implement this practice in the NICU setting, and whether this practice improves not just identification of unmet social needs, but more importantly connection with community resources among families,” explains first author Erika Cordova Ramos, MD, assistant professor of pediatrics at Boston University Chobanian & Avedisian School of Medicine, in a new study.

To address this, researchers at the School and Boston Medical Center (BMC) conducted a quality improvement initiative to increase rates of systematic social risk screening and connect families with community resources. At BMC, they found an extremely high burden of unmet social needs among NICU families (84 percent had greater than one and 64 percent had greater than two unmet needs).

The researchers built a multidisciplinary team including clinicians, social worker and family partners. This team adapted an electronic-health-record based social risk screener and developed a resource guide. They then used quality improvement methods to integrate social risk screening and referrals into routine clinical workflows. Among families requesting assistance, 98 percent received referrals. Continuous updating of a written resource guide and community partnerships led to increased rates of connection with resources from 21 to 52 percent.

“We demonstrated that it is feasible and acceptable to staff and families to leverage existing staff and resources to implement standardized social risk screening and referral in the NICU setting,” said Cordova Ramos, who also is a neonatologist at BMC.

According to the researchers, this intervention addressed both short and longer-term needs of caregivers of hospitalized newborns. “Alleviating short term needs (food, parking, transportation) serves to enable greater caregiver presence in the NICU, which increases opportunities for caregivers to participate in their infant’s care and engage in key health-promoting behaviors such as breastfeeding and skin-to-skin contact,” she added. While Cordova Ramos acknowledges that addressing longer-term needs, such as employment and educational advancement, is a complex process, the research found that early engagement with services and cross-sector partnerships yielded positive referral outcomes too.

These findings appear online in the journal Pediatrics.

Funding for this research was provided by the W.K. Kellogg Foundation (P0131665 PI Parker), the Boston Medical Center Department of Pediatrics Kids Fund, and the Evans Center for Implementation and Improvement Sciences (CIIS Department of Medicine, Boston University School of Medicine. Dr. Cordova-Ramos is supported by BU-CTSI Grant Number 1KL2TR001411.

Method of Research

Case study

Subject of Research


Article Title

Implementing Social Risk Screening and Referral to Resources in the NICU

Article Publication Date


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Schedule20 Apr 2024