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Research ArticleORIGINAL RESEARCHA

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

Margaret Greenwood-Ericksen, Melissa DeJonckheere, Faiyaz Syed, Nashia Choudhury, Alicia J. Cohen and Renuka Tipirneni
The Annals of Family Medicine July 2021, 19 (4) 310-317; DOI: https://doi.org/10.1370/afm.2690
Margaret Greenwood-Ericksen
1Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
MD, MSc
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  • For correspondence: mgreenwoodericksen@salud.unm.edu
Melissa DeJonckheere
2Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
3Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
PhD
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Faiyaz Syed
4Michigan Primary Care Association, Lansing, Michigan
MD
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Nashia Choudhury
5MyCare Health Center, Center Line, Michigan
MPH
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Alicia J. Cohen
2Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
6Center of Innovation in Long Term Services and Supports for Vulnerable Populations, Providence VA Medical Center, Providence, Rhode Island
7Departments of Family Medicine and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
MD, MSc
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Renuka Tipirneni
3Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
8Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
MD, MSc
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  • RE: Commentary for "Implementation of Health-Related Social Needs Screening at Michigan Health Centerss"
    Reilly Kuhn, Emily Allison, Kailyn Baalman, Katrina Dovalovsky, Holly Garcia, Joshua Green, Stephen Tse and Jinghui Xiong
    Published on: 07 September 2021
  • RE: Important findings on screening for SDH but much more work needs to be done
    Brent C Williams
    Published on: 17 August 2021
  • Published on: (7 September 2021)
    Page navigation anchor for RE: Commentary for "Implementation of Health-Related Social Needs Screening at Michigan Health Centerss"
    RE: Commentary for "Implementation of Health-Related Social Needs Screening at Michigan Health Centerss"
    • Reilly Kuhn, Medical Student, University of Illinois College of Medicine Rockford
    • Other Contributors:
      • Emily Allison, Medical Student
      • Kailyn Baalman, Medical Student
      • Katrina Dovalovsky, Medical Student
      • Holly Garcia, Medical Student
      • Joshua Green, Medical Student
      • Stephen Tse, Medical Student
      • Jinghui Xiong, Medical Student

    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...

    Show More

    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).

    Show Less
    Competing Interests: None declared.
  • Published on: (17 August 2021)
    Page navigation anchor for RE: Important findings on screening for SDH but much more work needs to be done
    RE: Important findings on screening for SDH but much more work needs to be done
    • Brent C Williams, Professor of Medicine, University of Michigan

    Dear Editors:

    Screening for social determinants of health (SDH) is now being adopted by a growing number of health care systems across the United States. With scant evidence to support its effectiveness in improving health outcomes for individuals or populations, its use seems compelling given the strong role social, behavioral, and economic factors play in determining health outcomes.

    For screening for SDH (more accurately termed ‘case finding’) to be effective and feasible, at least three conditions must be met: a) the condition must be reasonably prevalent, b) the condition must be amenable to interventions that improve outcomes, and c) resources and means to implement interventions must be available. Ideally, randomized controlled trials would provide the evidence informing best practices. Although some trials are ongoing (1), few of these criteria have been met to guide current efforts to screen for SDH in health care settings. There are compelling reasons to believe they will be difficult to achieve under current funding and organization of health systems and social service organizations.

    In this context, the article by Greenwood-Ericksen and colleagues (2) on social needs screening in Michigan provides important, incremental insight into some important issues surrounding health systems’ efforts to address social determinants of health (SDH). Through a systematic series of interviews, authors investigated reasons for observed variation in...

    Show More

    Dear Editors:

    Screening for social determinants of health (SDH) is now being adopted by a growing number of health care systems across the United States. With scant evidence to support its effectiveness in improving health outcomes for individuals or populations, its use seems compelling given the strong role social, behavioral, and economic factors play in determining health outcomes.

    For screening for SDH (more accurately termed ‘case finding’) to be effective and feasible, at least three conditions must be met: a) the condition must be reasonably prevalent, b) the condition must be amenable to interventions that improve outcomes, and c) resources and means to implement interventions must be available. Ideally, randomized controlled trials would provide the evidence informing best practices. Although some trials are ongoing (1), few of these criteria have been met to guide current efforts to screen for SDH in health care settings. There are compelling reasons to believe they will be difficult to achieve under current funding and organization of health systems and social service organizations.

    In this context, the article by Greenwood-Ericksen and colleagues (2) on social needs screening in Michigan provides important, incremental insight into some important issues surrounding health systems’ efforts to address social determinants of health (SDH). Through a systematic series of interviews, authors investigated reasons for observed variation in screening for SDH among Federally Qualified Health Centers in Michigan. The high prevalence of SDH among patients at FQHCs made the study sites ideal for investigating influences on screening practices. Key findings included that screening practices were not evidence-driven, but influenced mainly by local and state policies, funding opportunities, leadership, and configuration of local practices. While screening tools were chosen from existing standardized instruments, implementation and follow up of findings varied across centers. Importantly, screening for SDH was part of a state initiative that included funding for Community Health Workers (CHWs), who were centrally involved in screening and follow up at the sites. Since all sites used CHWs, the incremental effect of CHWs on screening practices could not be studied.

    While not designed to build evidence for best screening practices, the study by Greenwood-Ericksen and colleagues nonetheless provides relevant insights. First, standardized screening protocols across systems are desirable, to allow for meaningful comparisons. Second, within practices some variation from standard protocols will be necessary to accommodate local conditions among patients, health center resources, and leadership. Third, areas for improvement and further learning include integrating findings into electronic medical records so they can be routinely guide interventions and follow-up, and application of the findings to inform population-level interventions in a local geographic area.

    The current frenzy of screening for SDH should be better informed by evidence to ensure effectiveness in improving health outcomes. We look forward to further studies like this, as well as randomized trials, to inform best practices to improve population health.

    1. Accountable Health Communities. First Evaluation Report. December 2020. Smith LR. RTI International. Available at: https://innovation.cms.gov/data-and-reports/2020/ahc-first-eval-rpt. Accessed August 17, 2021.
    2. Greenwood-Ericksen M, DeJonckheere M, Syed F, Choudhury N, cohen AJ, Tipirneni R. Implementation of health-related social needs screening at Michigan Health Centers: A qualitative study. Ann Fam Med July, 2021. 19(4):310-17. https://doi.org/10.1370/afm.2690

    Brent C. Williams, MD, MPH
    Medical Director, Complex Care Management Program
    Michigan Medicine
    Ann Arbor, Michigan
    bwilliam@umich.edu

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 19 (4)
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Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study
Margaret Greenwood-Ericksen, Melissa DeJonckheere, Faiyaz Syed, Nashia Choudhury, Alicia J. Cohen, Renuka Tipirneni
The Annals of Family Medicine Jul 2021, 19 (4) 310-317; DOI: 10.1370/afm.2690

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Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study
Margaret Greenwood-Ericksen, Melissa DeJonckheere, Faiyaz Syed, Nashia Choudhury, Alicia J. Cohen, Renuka Tipirneni
The Annals of Family Medicine Jul 2021, 19 (4) 310-317; DOI: 10.1370/afm.2690
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