Network Stories

Improving Screening and Referrals for Social Determinants of Health

Randall Children’s Hospital (RCH) Neonatal Intensive Care Unit (NICU), a 45 bed Level IV referral center in Portland, Oregon, has received funding through the VON Take Action to Follow Through health equity grant program to improve screening and referrals for social determinants of health.

The NICU parent liaison will perform screening of mothers at seven to ten days into their infant’s hospitalization (or sooner if the baby is ready for discharge). Screenings will occur in person or by phone and use the mother’s native language. The NICU social worker or case manager will meet with mothers who screen positive for SDOH and provide referrals to services such as the Healthy Families Oregon Initiative or other mental health, substance abuse, and legal resources. Matching funds are being provided by Northwest Newborn Specialists to support the program.

To measure the impact of this standardized screening and referral program, the team will record:

  • The number and percent of NICU moms screened for SDOH.
  • The number and percent of NICU moms identified with risk factors.
  • The number and percent of NICU moms identified by screening with risk factors who are referred for resources.
  • The types and numbers of identified risk factors.
  • The number and percent of referred NICU moms who engage with referral resources.
  • Qualitative feedback from NICU moms about referral resources.

Each of the above measures will be stratified by race and ethnicity.

The Take Action to Follow Through grant program supports the development of innovative programs that confront health inequities and that can spread across our community of practice. The Potentially Better Practices at the core of the grant program are central to the VON quality improvement collaboratives.