Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

The overall purpose of this study was to assess any differences in the social determinants of health screening for patients at Federally Qualified Health Center (FQHC). Social determinants of health (SDOH) are posing a serious threat to the overall health of our communities; thus, it is important to screen patients for SDOH. Many of these factors are now included in a SDOH screening tool. However, there seems to be a lot of unexplored variation in what is being screened, who is being screened, and how they are being screened. The authors of this study designed a qualitative approach to determine the drivers in the screening processes and the way the screening is implemented in various FQHCs.

This study was designed to analyze SDOH screening processes in five FQHCs that were selected for maximum variation. Site visits and 4-5 interviews per site were performed. Snowball sampling was used to identify individuals within each FQHC to obtain diversity in perspectives. There were 23 participants from the 5 different sites that were interviewed. The group felt it was important to have that differed in patient age, geography, race/ethnicity, and insurance status to provide a broad perspective on the factors affecting the overall health of their patients and the community.

There were four major themes that the study determined to be important when exploring the variation in screening techniques of social factors at the FQHCs: (1) variation in screening practices (2) shift in the community health worker roles (3) variable integration of screening data and (4) barriers limiting the impact of screening. Our group discussed the facilitators and barriers associated with each of the themes.

When analyzing the first theme, it is important to know who is being screened and how the screening tool is being delivered. At each site, there was a different patient population that was screened. In our opinion, to avoid bias/assumptions, it is important to screen all patients for potential social determinants of health. From a health equity perspective, it is not appropriate to make assumptions about which type of patients may have extra challenges with their health and might need a SDOH assessment. At one site in this study, screening was only performed for patients that were already enrolled in a grant funded diabetic program. This limits the patient population to only those with diabetes. It is also critical to have several different delivery methods when administering the screening tool to account for literacy level, fear of judgement, and allow for identification of resources if we find many people have a similar shortcoming.

The second theme discussed was the role of the community health worker (CHW) and the benefit of this role in many various communities. While some communities are still not able to add the CHW position, it is important to discuss their abilities and the benefit in training and teaching a CHW for their benefit to the community. Our group discussed that to have a CHW to do the assessment can prevent adding onto an already busy physician schedule, while also providing valuable resources to the patients in need. The main concern for the addition of CHW’s is the ability to sustain the positions long-term, as well as the need for possible reimbursement for their services.

The third theme discussed was the challenge and importance of integrating these screening methods/tools into an electronic medical record or into the records that are present at the FQHC. Currently, each health system has its own medical record system in which information is stored and recorded. While we perform these screening tools to assess different social determinants of health, it must be recorded in the patient chart so that these problems and concerns can be addressed and not slip through the cracks from visit to visit. It is essential that there be some way to handle the documentation and resource allocation when discussing social determinants of our patients’ health. Just as lab work, imaging, and provider notes are documented, so should these social factors, as they are as important to the overall health of the patient.

Finally, the fourth theme was the barriers that limit the screening assessments. It was mentioned in our group that we can screen as many individuals and patients as we would like, but that we need to have resources lined up to address the patients’ needs related to social determinants. Screening patients is important, but it requires that everyone in the care team must be aware of different resources that can be provided. The time that it takes to do this screening in the FQHCs is extensive and there must be time set aside for this to happen. It is also necessary that there is sufficient funding to continue to provide this level of quality care and screening methods. And lastly, another barrier that is present is the lack of standardization in screening. Each FQHC screens differently and obtains different information. While it provides information for individual care, it can be difficult to understand what each community may need as far as resource allocation.

Our group agreed on the four themes that were mentioned and discussed in the article. FQHCs are an important part of medical care in underserved communities and identifying social determinants of health and alleviating healthcare barriers within those communities is a major goal of a FQHC. We believe that it is essential to screen all patients, regardless of race, ethnicity, education status, age, insurance status etc., for any factors that may be negatively impacting the way they care for their overall health. As mentioned, to eliminate any barriers that are present regarding these social determinants of health, we must first identify them, and then find specific resources within the community that may benefit the patient(s).