P3.C057: Tigers Connect: Bridging the Gap of Social Determinants of Health for Families

Background: The introduction of Pediatrics Collection: Social Determinants of Health emphasizes the disproportionate impact social determinants of health have on the health and well-being of marginalized populations. As recommendations and reimbursement increase for social determinants of health screening, it is imperative that we are thoughtful about how we best utilize this information to support families. Our clinical model can serve as a framework for other clinics in addressing these concerns.

Project Description: Tigers Connect aims to address disparities that children and families face in accessing resources in mid-Missouri. Modeled after the original Health Leads national program, Tigers Connect acts as a bridge between children and families at our primary care clinic, MU Pediatrics, through trained volunteers. These volunteers connect families with needed resources.
Each family coming in for a well child visit receives an anonymous screener to identify families both in need of resources and wanting assistance. Trained volunteers, known as Family Resource Specialists (FRS), are present in clinic to briefly meet with families and arrange time for follow-up. The FRSs have a tiered support system, including clinic Healthy Steps coordinators and the state-wide Parent Link Warm Line, to aid in finding resources. They then work with families over time to overcome barriers, such as lack of transportation or filling out applications, to address these needs.

Discussion: We have learned a great deal since Tigers Connect began in February 2021. In that time, we have administered over 9,500 screens, assisted 339 families and trained over 100 volunteers. The program supports a variety of learners and their growth. In surveys, volunteers have stated that it has changed their understanding of families in our community and the impact SDOH have on health.
We were purposeful in creating a universal screener, based on the validated Health Leads survey, which has allowed us to face inherent biases in who we would think would need assistance. The screener is anonymous from the EMR in order to protect families and provide a safe space for discussion. Also, volunteers are trained to emphasize family goals and existing strengths in their conversations to empower families. Finally, this work is only possible in conjunction with multiple partnerships. In clinic, we team with Healthy Steps coordinators, a nationally recognized program of Zero To Three and ParentLink, a non-profit community organization with a database of state-wide resources.

Conclusion: How we support families in addressing identified health needs, including social determinants of health, is even more important than whether we screen for them. For clinical settings that do not have access to an institutionally funded social worker, innovative models are needed to assist families. The Tigers Connect program is a sustainable, fiscally efficient model for addressing some of the barriers families face.