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Setting a new standard for socially accountable care

Social health screening is helping identify barriers and connect families with meaningful supports

Photo: Danfeng Li and her three children

When Danfeng Li first came to Holland Bloorview seeking support for her oldest son who was showing signs of autism, she expected to discuss assessments, services and developmental needs. What she didn't expect was that a conversation about her family's social circumstances would become a turning point in their lives.

For many families, social factors such as housing instability, financial stress, transportation challenges, caregiver well-being and access to community supports can have a significant impact on their health and ability to access care. Through social health screening, Holland Bloorview is better able to understand these challenges, identify barriers to care, tailor supports to each family's unique needs and connect families with resources that can improve their overall health and well-being.

For Danfeng, those challenges had become overwhelming.

After concerns about her son's development emerged when he was around two years old, she began a long journey through assessments, referrals and services. As a newcomer to Canada from China with no family nearby, she was navigating an unfamiliar system alone. At the same time, she was caring for three young children, coping with significant personal and financial pressures and navigating a complex system without knowing what supports were available to her.

"I was so depressed," recalls Danfeng. "I was dealing with my son's diagnosis, taking care of my children and trying to figure everything out on my own. I felt like I had nobody." 

That changed the moment Danfeng was connected with the Family Navigation Hub, as a result of the hospital's social health screening process. 

Understanding families’ unique needs

Social needs screening gives families a chance to share concerns that may otherwise go unnoticed during a clinical visit. By understanding the broader circumstances affecting daily life, care teams can connect them with resources and supports that reduce barriers and improve access to care.

 

Four people having a meeting in a library setting
L-R: Tammy Chong, social worker, Jessica Reid, social worker  and team lead, Family Navigation Hub and students

 

More than 65 per cent of families screened report at least one unmet social need. That tells us we have an opportunity, and a responsibility, to act. Social health is health. By addressing social factors as an integral part of healthcare, aligned with our commitment to socially accountable care, we can improve outcomes for children, youth and families and contribute to healthier communities.

Jessica Reid“When families share their experiences, it helps us identify both individual needs and broader trends across our community,” shares Jessica Reid, social worker and team lead, Family Navigation Hub. “That insight allows us to connect families with supports while also informing improvements to programs, services and care delivery.”

 

For Danfeng, that support was transformative.

Through the Family Navigation Hub, she was connected to community organizations, legal supports, tax clinics, housing resources, caregiver programs and funding opportunities for her children. She received help applying for benefits, gathering documentation and navigating systems that previously felt impossible to understand.

"At that time, I knew nothing," says Danfeng. "If you don't know these systems, you don't know where to start. Jessica gave me resources, explained what supports were available and connected me with people who could help." 

Turning information into action

The Family Navigation Hub is one example of how Holland Bloorview is transforming health equity and social health screening into meaningful support for families.

Lyndsay Tchegus-Veiga"Families tell us that navigating health, education, social services and funding systems can be incredibly complex. For families of children with disabilities and developmental differences, these challenges are often compounded by the need to coordinate supports across multiple systems," says Lyndsay Tchegus-Veiga, senior director, Client & Family Integrated Care, Transitions and Community Partnerships. "When we take the time to understand their challenges, we can partner with them to provide services that are responsive to their unique needs and circumstances." 

"It felt like family"

Today, Danfeng continues to access supports for her children and remains deeply grateful for the care, guidance and encouragement she received at Holland Bloorview.

"It felt like family,” she says. “It felt like somebody was there to hold you up when you were falling. I will never forget what they did for us." 

As she reflects on her journey, Danfeng hopes other families will feel empowered to ask for help when they need it.

"Don't suffer quietly," she says. "When you share your situation, people can help. That's what made the difference for me."

Joanne Maxwell“Stories like Danfeng's highlight how a child's health and well-being are influenced by the broader circumstances affecting their family,” says Joanne Maxwell, vice president, experience, transformation and social accountability (ETSA). “Through social health screening, we're creating opportunities to better understand the realities families face and respond in ways that are meaningful and supportive. This work is an important part of our commitment to socially accountable care, ensuring that every child, youth and family has access to the resources and supports they need to reach their full potential.”

Resources:

We encourage families to explore the resources below to learn more about the programs, services and community supports available through Holland Bloorview and our partners.

 

By Terry Mutuku