Strong Children Wellness Medical Group opened its first in-person location last August in the Jamaica neighborhood of Queens through a partnership with the Child Center of New York. Below-average incomes and above-average housing costs characterize the area, as do high rates of food assistance enrollment as well as poor access to child care and banking services. Jamaica has a legacy of redlining and is home to a diverse population of mostly Black, Asian and Latino people who face rising costs as the community undergoes gentrification.

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

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The founders created this model to address inefficiencies they observed in their old practices that complicated screening patients for social risks and connecting them to outside resources, Brown said. The pediatricians wanted to eliminate the phone calls, travel and other social barriers that come between patients and the support they need to stay healthy. Strong Children Wellness employs a two-way internal screening and referral program with its partners. A community navigator works with each family across all those services.

“We’ve built what I call an ecosystem of support to address all of those other needs,” Brown said. “Before, it was really difficult for families to navigate. We would kind of refer and hope for the best. Then we’ d see the family back three to six months later. In most instances, the issue was either not addressed or worse.”

The medical group works with RiseBoro, a Brooklyn-based not-for-profit housing organization to serve patients at risk for evictions or behind on rent, for example. Pediatricians assign those families to community navigators who coordinate with the housing group. The collaboration works in the other direction as well, when Riseboro and other partners refer patients to the clinics.

About 8 in 10 patients the clinics refer actually get the support they seek, Brown said. Roughly half of patients require referrals, mainly for behavioral and mental healthcare, housing and nutrition support, she said.

“The services are there. Social services in the city are pretty robust,” Brown said. “It’s just ensuring that connections are made, that they’re followed through and that families are actually benefited. That’s what the challenges are in healthcare and what we’re trying to solve for with this reverse-integration model.”