WED-010 - Advancing Health Equity: Integrating Social Determinants of Health Screening into Care Management
Wednesday, April 22, 2026
12:30 PM - 1:30 PM PST
Location: Plaza Foyer, Plaza Level
Area of Responsibility: Area I: Assessment of Needs and Capacity Keywords: Child and Adolescent Health@@@Health Equity@@@Social Determinants of Health (SDOH), Subcompetencies: 1.3 Analyze the data to determine the health of the priority population(s) and the factors that influence health., 1.4.4 Develop recommendations based on findings. 1.4.5 Report assessment findings. Research or Practice: Practice
At the end of this session, participants will be able to:
Describe strategies for advocating SDoH screening within care management organizations to promote health equity.
Implement evidence-based SDoH screening and referral processes to connect marginalized families to community resources.
Implement evidence-based SDoH screening and referral processes to connect marginalized families to community resources.
Brief Abstract Summary: Learn how Bergen’s Promise advanced health equity by implementing Social Determinants of Health (SDoH) screening and referral for youth with mental health challenges and their families. A 2025 pilot using the evidence-based WE CARE model identified unmet social needs often overlooked in traditional assessments and connected families to community resources, reducing barriers and strengthening support. This session highlights the process of advocating for SDoH screening, piloting the intervention, and scaling it agency-wide, including staff training, electronic health record integration, and formalized community partnerships. Attendees will gain strategies to embed systematic SDoH screening and referrals into care, promote social justice, and improve outcomes for marginalized and vulnerable populations.
Detailed abstract description: Persistent inequities in housing, food security, access to healthcare, and other social determinants of health (SDoH) continue to undermine family stability, youth mental health, and long-term success. Bergen’s Promise recognized the need to systematically address these upstream factors through structured advocacy, screening, and referral processes.
In early 2025, the agency piloted the WE CARE model (Well childcare visit, Evaluation, Community resources, Advocacy, Referral, Education), a family-centered, evidence-based SDoH screening and referral system developed by the Child Health Equity Center at UMass Chan Medical School. The pilot revealed critical unmet social needs that were not captured in existing assessments and connected families to community resources through a curated directory. Families reported increased support, reduced barriers, and improved engagement with care.
Building on pilot success, Bergen’s Promise is implementing SDoH screening agency-wide to embed health equity into care management practices. Key components include:
-Training all staff in SDoH screening, referral, and family-centered communication practices.
-Integrating screening into initial family engagement assessments and embedding results in the electronic health record.
-Expanding the resource toolkit and formalizing partnerships with community providers.
This initiative addresses social justice by proactively identifying and addressing inequities that impact youth and families, promoting equitable access to community resources, and enhancing integrated care outcomes. Attendees will learn strategies to advocate for and implement SDoH screening, strengthen community partnerships, and embed equity-focused practices into organizational workflows. The session provides actionable approaches for health educators, program planners, and care managers seeking to reduce systemic barriers and advance social justice in health education and promotion.
