NYC pediatricians aim to scale clinical model built into social services

Last August, Strong Children Wellness Medical Group opened its first personal office in the Jamaican area of ​​Queens through a partnership with the New York Children’s Center. Below average income and above average housing costs characterize the area, as do high levels of food aid coverage, as well as poor access to childcare and banking services. Jamaica has a legacy red line and is home to a diverse population of mostly blacks, Asians and Hispanics who are facing rising costs as the community is exposed to gentrification.

On the fourth floor of a seven-story brick building built in 1945 on Jamaica Avenue, children and their families receive physical and mental health services, supplementary nutrition services, vocational training, youth programs, and access to technology. The medical group also opened a site in the Queens Flushing area with a foster care agency that is responsible for almost 9,000 children. Each facility includes full-service examination rooms, behavioral and mental health services, and can refer patients to nearby resources for help with issues such as homelessness, incarceration, immigration, unemployment, food insecurity, and domestic violence .

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Brown said the founders created this model to address inefficiencies they saw in their old practice that made it difficult to screen patients for social risks and connect them to external resources. Pediatricians wanted to eliminate phone calls, travel and other social barriers that come between patients and the support they need to stay healthy. Strong Children Wellness operates a two-way internal screening and referral program with its partners. The Community Navigator works with every family on all of these services.

“We have created what I call a support ecosystem to address all of these other needs,” Brown said. “It used to be very difficult for families to navigate. We would like to reach out and hope for the best. Then we will see the family again in three to six months. In most cases, the problem was either not solved or even worse.”

The medical group is working with RiseBoro, a Brooklyn-based nonprofit housing organization, to, for example, serve patients facing eviction or past due rent. Pediatricians assign these families to community navigators who coordinate with the housing group. The collaboration also works in the other direction, with Riseboro and other partners referring patients to clinics.

About 8 out of 10 patients who are referred to clinics actually get the support they need, Brown said. About half of the patients require referrals, she said, mostly for behavioral and mental health care, housing and nutritional support.

“The services are there. Social services in the city are pretty reliable,” Brown said. “It’s just about making sure the connections are made, that they stick, and that the families actually benefit. This is where the problems in healthcare lie and what we are trying to solve with this backward integration model.”

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