Implementing a Social Needs Screening and Intervention Program at a Pediatric Diabetes Center

Social risk strongly influence diabetes control and contribute to inequity in diabetes care. We aimed to improve and sustain health-related social needs (HRSNs) screening of patients with diabetes from 0 to >50% over a 2-year period at multiple clinic sites within a pediatric hospital center. Using a multidisciplinary team and quality improvement techniques, we implemented and maintained an intervention over a 2-year period to screen for HRSNs and connect those with positive screens to local resources. We used statistical process control to assess change over time. Screening for HRSNs increased from 0% to 68% within 3 months and was maintained at a mean of 62% for the subsequent 20 months. Overall, 9026 screens were completed, with 956 (11%) positive for HRSNs. Of those, 146 (15%) requested direct assistance with connecting to resources, 507 (47%) requested resources to self-navigate, and 305 (32%) declined wanting assistance. Less than 1% of screens (n = 48) required urgent intervention from clinical social workers. Implementation of universal HRSN screening within a pediatric diabetes clinic is feasible across multiple clinic locations.