The evidence base

Family Screening and Connection to Services

Our home, school, neighborhood, and community environments have important implications for our health. Unaddressed social determinants of health (SDOH) – conditions in the places where people live, learn, work, and play – can lead to negative effects on a child’s physical health and development and social-emotional well-being.

Thus, identifying concerning SDOH family risk factors and intervening early as part of standard pediatric care is an important prevention strategy for child health and is recommended by the American Academy of Pediatrics. [4] However, family needs related to SDOH continue to be unaddressed in well-child care and remain a focus of several national initiatives including Healthy People 2030. [5][6]

How HealthySteps Supports Family Screening and Connection to Services


The HealthySteps Specialist (HS Specialist) joins the pediatric primary care team to ensure universal screening for family needs. At a minimum, this includes asking families to complete questionnaires about maternal depression, food insecurity, housing instability or homelessness, utility needs, transportation needs, interpersonal safety (e.g., domestic violence, interpersonal violence, community violence, etc.), substance misuse (alcohol and other drugs), and tobacco use.

When concerns are raised, the pediatric primary care provider and the HS Specialist will meet with a family. If a referral is needed, HS Specialists partner with community resource providers to help parents coordinate and navigate complex systems and offer families close follow-up and support to ensure resources are accessed.

Research on HealthySteps demonstrates that HealthySteps identifies family needs early and successfully connects families with services.


  • Mothers were significantly more likely to discuss their depressive symptoms and pediatric providers were significantly more likely to discuss postpartum depression with mothers. [7][8][9]
  • Families were 4x more likely to receive information on community resources [7]
  • Families had significantly higher rates of nonmedical referrals, including referrals for maternal depression, child abuse or neglect, marital or family issues, and other social or environmental issues or agency referrals [7]
  • A quality improvement project in two HealthySteps practices increased maternal depression screening from 41% to 95% in just 19 weeks in one site and from 31% to 60% in just 11 weeks in the other 
  • A quality improvement project in one HealthySteps practice increased maternal depression referral follow up from 49% to 67%; another practice reported a 70% follow-up visit rate for mothers with maternal depression [10][11]
  • A study in three HealthySteps practices found a successful referral rate of 87% [12]

[1] The Centers for Disease Control and Prevention (2021). Social Determinants of Health: Know what Affects Health. Accessed 4/12/21.

[2] Weinreb, L., Wehler, C., Perloff, J., Scott, R., Hosmer, D., Sagor, L., Gundersen, C. (2002). Hunger: Its impact on children’s health and mental health. Pediatrics, 110(4):e41.

[3] Rose-Jacobs, R., Black, M.M., Casey, P.H., Cook, J.T., Cutts, D.B., Chilton, T.H., Levenson, S.M., Meyers, A.F., Frank, D.A. (2008). Household food insecurity: Associations with at-risk infant and toddler development. Pediatrics, 121(1):65-72.

[4] American Academy of Pediatrics, Council on Community Pediatrics. (2016). Poverty and child health in the United States. Pediatrics, 137(4).

[5] Drouin, O., Winickoff, J.P. (2018). Screening for behavioral risk factors is not enough to improve preventive services delivery. Academic Pediatrics, 18(4):460-467.

[6] Beck, A., Tschudy, M.M., Coker, T.R., Mistry, K.B., Cox, J.E., Gitterman, B.A., Chamerlain, L.J., Grace, A.M., Hole, M.K., Klass, P.E., Lobach, K.S., Ma, C.T., Navsaria, D., Northrip, K.D., Sadof, M.D., Shah, A.N., Fierman, A.H. (2016). Determinants of health and pediatric primary care practices. Pediatrics, 137(3):e20153673..

[7] Guyer, B., Barth, M., Bishai, D., Caughy, M., Clark, B., Burkom, D., Genevro, J., Grason, H., Hou, W., Keng-Yen, H., Hughart, N., Snow Jones, A., McLearn, K.T., Miller, T., Minkovitz, C., Scharfstein, D., Stacy, H., Strobino, D., Szanton, E., & Tang, C. (2003). Healthy Steps: The first three years: The Healthy Steps for Young Children Program National Evaluation.

[8] Johnston, B.D., Huebner, C.E., Anderson, M.L., Tyll, L.T., & Thompson, R.S. (2006). Healthy Steps in an integrated delivery system: Child and parent outcomes at 30 months. Archives of Pediatrics & Adolescent Medicine, 160(8), 793–800.

[9] Buchholz, M., & Talmi, A. (2012). What we talked about at the pediatrician’s office: Exploring differences between Healthy Steps and traditional pediatric primary care visits. Infant Mental Health Journal, 33(4), 430–436.

[10] Preliminary data from HealthySteps Outcome Pilots Study.

[11] Fried, E., Hernandez, C., Ringwood, H., & Tomcho, M. (2019, Oct 2 – Oct 5) Creative solutions to postnatal Care: Mom-baby dyad visits in a pediatric setting [Conference Session]. ZERO TO THREE Annual Conference, Hollywood, FL.

[12]German, M., et al. (2021). Impact of Community Healthy Workers on Community Referrals with an Integrated Primary Care Setting. Manuscript in preparation.