​​This page features social determinants of health resources, tools, and educational offerings developed by the National Resource Center for Patient/Family-Centered Medical Home to support the implementation of social determinants​ of health screening, referral and follow-up at the clinical, community, and state level. 

Developed by the National Resource Center for Patient/Family-Centered Medical Home, the Action Learning Collaborative (ALC) was a 8-month quality improvement project, highlighting collaborations between state agencies and clinical practices. The goal of the ALC was for teams to work collaboratively to advance patient/family-centered medical home by strengthening state partnerships; increasing screenings for social determinants of health (SDoH); increasing referrals and linkages to local and community resources after positive screenings for SDoH are identified; identifying protective factors for social/emotional health in partnership with families; and increasing access to a patient/family-centered medical home. Tools and resources developed for the ALC are available below. 

The National Resource Center for Patient/Family-Centered Medical Home (NRC-PFCMH), in partnership with Bright Futures National Center and the Screening Technical Assistance and Resource (STAR) Center, implemented an educational webinar series, Making Connections: The Critical Role of Family-Centered Care in Addressing Social Determinants of Health​ for Children and Youth with Special Health Care Needs (CYSHCN).

The goal of this 2-part webinar ​series was to pr​ovide state Title V Maternal and Child Health (MCH) / CYSHCN programs, pediatricians, families, and others with information about the impact of social determinants of health on CYSHCN and their families, including implementation strategies for state programs. The series discussed the role of these groups and state systems in addressing SDOH for CYSHCN by using components of the medical home model.

The first webinar in this series will provided relevant​ background information about how CYSHCN are impacted by SDOH, including a review of current data. The second webinar featured 2 state Ti​tle V MCH / CYSHCN programs who will discuss how their states are addressing SDOH for CYSHCN.

Developed by the National Resource Center for Patient/Family-Centered Medical Home, in partnership with the National Academy for State Health Policy, this fact sheet series discusses​ social determinants of health (SDoH) screening and referrals for children and youth with special health care needs (CYSHCN) and their families. Opportunities for collaboration and partnership between Medicaid, Title V Maternal and Child Health / CYSHCN programs, and pediatricians are discussed. State-level case studies provide innovative and replicable strategies for implementing SDoH screening and community referrals. 

Visit the Screening and Tech​​​ni​cal Assistance Resource (STAR) Center for more tools, resources, and recommendations for SDoH screening, referral, and follow up. ​​​