Social determinants of health (SDoH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDoH screening/referral with a standardized tool is recommended in clinical encounters by the AAP and CMS.

ln the NICU, SDoH screening and referral has increased in the out-patient pediatric setting, but has not yet come to scale in the NICU. National survey study of NICUs indicates that national prevalence of SDoH screening/referral using a tool was 23% in 2021(Cordova Ramos et al, Hospital Pediatrics 2022).

This collaborative is starting out with 5 hospitals working towards the goal of identifying and addressing adverse social determinants of health in the neonatal setting. The 5 hospitals include Baystate Medical Center, Boston Medical Center, Lowell General Hospital, Tufts Medical Center, and UMass Memorial Medical Center. These hospitals were chosen due to a large proportion of low-income families with a need for SDH referrals. There is also a range of geographic location, combination of level 2 and 3 NICUs, and a range of discharge home vs. transfer to a level 2.

The SDoH of interest to this project include, but are not limited to: housing, food, transportation, energy/heat, employment, education, childcare.