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Care coordination effectively addresses social determinants of health (SDoH) for premature infants. Consistent reassessment by care coordinators connects families to vital resources, improving engagement and health outcomes.

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Area of Science:

  • Neonatal Intensive Care Unit (NICU) care coordination
  • Social Determinants of Health (SDoH) screening and referral

Background:

  • SDoH significantly impact health outcomes, particularly for vulnerable populations like premature infants.
  • Effective screening and referral are crucial for addressing SDoH in high-risk neonatal populations.

Purpose of the Study:

  • To examine the effectiveness of care coordination (CC) in enhancing social determinants of health (SDoH) screening and resource referral in a level IV NICU.
  • To assess the impact of CC on connecting families with essential resources and improving health outcomes.

Main Methods:

  • Retrospective descriptive study of infants enrolled in CC in 2022.
  • Assessed completion rates of SDoH screenings, resource referrals, and subsequent outcomes.
  • Focused on the role of CC staff in SDoH assessment and support.

Main Results:

  • Only 28% of SDoH screenings were completed within 24 hours of admission; however, 96% were reassessed by CC.
  • Top resources provided included care advisors, family services, and financial assistance.
  • Connection rates to referred resources ranged from 81% to 91%.

Conclusions:

  • Longitudinal CC is vital for understanding and supporting family SDoH needs.
  • Flexible and early SDoH screening, coupled with CC reassessment, improves resource connection and engagement.
  • Ongoing CC support reduces barriers, builds trust, and fosters better health outcomes for NICU infants and families.