105 - Small Patients, Big Needs: Implementing Social Drivers of Health (SDoH) Screening Across the NICU Continuum

Publication Number: 4103.105

Isabella C. Norelius, Medical College of Wisconsin, Milwaukee, WI, United States; Bethany Korom, Medical College of Wisconsin Affiliated Hospitals, Inc. - - Milwaukee, WI, Milwaukee, WI, United States; Alicia Sprecher, Medical College of Wisconsin, Milwaukee, WI, United States; Susan Cohen, CW HOPE Developmental Follow Up Clinic, Milwaukee, WI, United States; Katherine Carlton, Medical College of Wisconsin, Mequon, WI, United States

Background: Infants in the neonatal intensive care unit (NICU) experience disproportionately high social risk. However, social drivers of health (SDoH) screening occurs inconsistently during NICU hospitalization and high-risk infant follow-up (HRIF) visits.

Objective: We aimed to implement a standardized SDoH screening process across NICU and HRIF encounters, achieving >90% screening completion.

Design/Methods: This multi-setting quality improvement (QI) initiative spanned a 76-bed level IV NICU (70% inborn) and two HRIF clinics. Approximately 50% of NICU patients are referred to one of two HRIF clinics based on their neurologic complexity; staff differ across sites. A multidisciplinary QI team, including physicians, advanced practice providers, nurses, medical assistants, social workers, and a medical student, developed a key driver diagram to identify drivers and change ideas for standardizing SDoH screening (Figure 1). Three plan-do-study-act (PDSA) cycles were implemented: 1) workflow optimization in a single-provider HRIF clinic (5/1/25), 2) pilot program in a multidisciplinary HRIF clinic (6/1/25), and 3) nursing-led screening in the NICU (9/1/25). Each PDSA cycle was tailored to local workflows to ensure feasibility and sustainability. The outcome measure was the proportion of encounters with a completed SDoH screen. Process measures included screening distribution, social risk identification, and social work consultations. The balancing measure was healthcare team workload assessed via anonymous survey. Statistical process control charts evaluated intervention impact.

Results: SDoH screening increased from 85% to 93% in the single-provider HRIF clinic (Figure 2A) and from 19% to 78% in the multidisciplinary clinic (Figure 2B). In the NICU, SDOH screening remains at 25% but is uptrending since implementing nursing-led screening (Figure 2C). Patients with positive screens were universally offered community resources and social work referral. Healthcare staff reported no increase in workload to date. Social risk factors were identified in 28%, 17%, and 21% of patients in the single-provider HRIF, multidisciplinary HRIF clinic, and NICU, respectively.

Conclusion(s): Engaging key stakeholders and tailoring workflows enabled consistent SDoH screening without added burden to the healthcare team. This initiative demonstrates feasibility of standardized SDoH screening across inpatient and ambulatory settings. Ongoing work will evaluate long-term sustainability and system-wide implementation.

Figure 1. Key Driver Diagram
Key driver diagram illustrating the primary drivers and change ideas for improving social drivers of health (SDoH) screening across the neonatal care continuum.

Figure 2. Statistical Process Control Charts
Statistical process control (P) charts showing the impact of social drivers of health (SDoH) screening interventions in a single-provider high-risk infant follow-up (HRIF) clinic (A), a multidisciplinary HRIF clinic (B), and a Level IV neonatal intensive care unit (NICU) (C).