In a groundbreaking randomized clinical trial published in JAMA Pediatrics in April 2025, researchers at the University of Chicago Medicine have demonstrated that a low-intensity intervention targeting social determinants of health can markedly reduce acute healthcare utilization among children from food-insecure families. The study, which uniquely applied a universal social care approach rather than targeting solely high-risk individuals, underscores the power of embedding community resource referrals into hospital discharge workflows. This innovation utilizes streamlined technology and minimal clinician time yet produces significant clinical and economic benefits, heralding a promising path toward sustainable pediatric healthcare delivery.
Social determinants of health, encompassing factors like food insecurity, housing instability, and transportation barriers, have long been recognized as critical contributors to health outcomes. Despite this, interventions to address these factors have often faced challenges due to resource intensity and operational complexity. Historically, programs aiming to connect families with social services have depended heavily on in-person social work or intensive case management, creating scalability barriers. The University of Chicago Medicine study disrupts this paradigm by demonstrating that digital prescription of community resources, coupled with automated follow-up, can achieve comparable reductions in acute care use with a fraction of resources.
The trial enrolled 640 parents and primary caregivers of hospitalized children across three years, randomly dividing participants into two groups: usual discharge procedures and an intervention group receiving a tailored “HealtheRx” — a printout customized to list local food pantries, rental assistance programs, transportation services, and other vital community resources. Uniquely, this intervention was universally delivered regardless of whether families initially screened positive for social needs, embracing the reality that social risk fluctuates over time and may emerge unexpectedly, such as during a child’s hospitalization.
Following discharge, caregivers in the intervention arm were enrolled in a three-month automated texting program delivering periodic reminders and fresh resource links. Importantly, caregivers were empowered to respond to texts, triggering personalized assistance from trained navigators throughout the subsequent year. This combination of technology and human touch provided scalable yet responsive support, ensuring that families could access additional help as their circumstances evolved without requiring staff-intensive direct outreach to all participants.
A critical aspect of this research was its double-blind design, making it the first of its kind in social care intervention studies. Neither families nor research staff knew which group received the HealtheRx intervention versus standard care, removing bias and providing gold-standard evidence for the effectiveness of this approach. This rigor lends substantial credibility to the findings, countering critiques that social care interventions lack sufficient methodological robustness.
The impact observed among food-insecure families was striking. At three months post-discharge, 69% of caregivers who received the intervention rated their child’s health as “excellent or very good,” compared with only 45% in the standard care group. More impressively, one year after intervention delivery, only 30% of children from food-insecure households in the intervention group visited the emergency department, compared to 52% among controls. Hospital readmissions trended downward as well, particularly for those families who proactively requested further resource information.
Comparatively, previous social resource interventions required as much as five hours of staff time per family, often involving home visits and direct appointments. In stark contrast, the CommunityRx-Hunger program studied here demanded approximately 50 total staff hours for the entire intervention cohort, highlighting its unprecedented efficiency. This reduction in human effort makes the model highly attractive to healthcare systems seeking scalable interventions amid growing pressures for cost containment and improved population health outcomes.
In estimating the economic implications, researchers applied national averages for pediatric emergency and inpatient costs, revealing an estimated $3,000 saved per food-insecure child over one year. These savings easily offset the technological costs related to automated messaging and navigator support, illustrating that strategic social care integration not only benefits patient well-being but also offers compelling value to healthcare payers and providers.
The study’s timing is especially pertinent given recent regulatory shifts. The U.S. Centers for Medicare and Medicaid Services recently proposed removing hospital directives requiring screening for social drivers of health. In the absence of mandated screening, universally-applicable interventions like CommunityRx-Hunger provide a vital pathway to address social needs without the risk of missing families who do not screen positive but still experience acute vulnerabilities. This universality also accommodates the dynamic nature of social risk, as families frequently transition in and out of precarious situations.
Notably, even among families initially classified as food secure, one-third sought additional assistance through the intervention, sometimes for urgent concerns such as mental health crises, safety issues, or emergency housing. This finding powerfully illustrates that social conditions are not static traits but ever-changing states influenced by circumstances, including the stress and disruption caused by a child’s hospitalization. Delivering social care universally thus ensures broader reach and equity in service delivery.
Moreover, the HealtheRx intervention extends its impact beyond individual recipients through community ripple effects. Past data from the broader CommunityRx program have demonstrated that over half of participants shared resource information with others, amplifying benefits across social networks and enhancing community resilience. This diffusion suggests that scalable, digitally-enabled social prescribing models can transform not only individual health trajectories but also strengthen support ecosystems.
From a practical standpoint, many U.S. health systems already license community-resource referral platforms and integrate texting tools, making replication of CommunityRx-Hunger highly feasible. Institutionalizing such low-intensity social care interventions within standard pediatric discharge protocols could soon become an integral component of holistic healthcare. Forward-looking hospitals may routinely complement traditional prescriptions and appointments with tailored resource lists and automated outreach, ushering in an era of socially informed medicine that proactively addresses upstream determinants of health.
This landmark study establishes compelling evidence that leveraging technology and community partnerships to uniformly “prescribe” social resources to families during pediatric hospital discharge is an effective, cost-saving strategy to reduce acute healthcare utilization. Its innovative design and striking outcomes highlight a scalable model with transformative potential for pediatric healthcare delivery — one that acknowledges the inseparability of social context and health and mobilizes simple, accessible tools to improve outcomes at scale. As hospitals nationwide grapple with rising costs and complex patient needs, integrating such low-intensity social care interventions may be key to healthier children, less stressed caregivers, and more sustainable health systems.
Subject of Research: People
Article Title: Low-Intensity Social Care and Child Acute Health Care Utilization: A Randomized Clinical Trial
News Publication Date: 28-Apr-2025
Web References:
- https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamapediatrics.2025.0484
- https://www.uchicagomedicine.org/forefront/prevention-and-screening-articles/uchicagos-communityrx-intervention-helps-patients-find-community-resources
- https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective
- https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0694
References: 10.1001/jamapediatrics.2025.0484
Keywords: Emergency medicine, Food security
