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

doi:10.1370/afm.2690

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Figure 1.
Components of multi-phase mixed methods study.
FQHC = Federally Qualified Health Center; SDOH = social determinant of health.

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Table 1.

Characteristics of Study Sites and Participants

		Site Characteristics (N = 5)			Participant Roles (N = 23)
Site	Geographic Setting	Payer Type Serving Population	Dominant Population Served	Participation in State Demonstration Program^{^a}	Administrators, No.	Screeners/Implementers, No.
1	Rural	Mix of insurance	White	Yes (Linkages, SIM)	1	3
2	Rural	Medicaid	White, young families, older adults	Yes (Linkages)	1	4
3	Urban	Medicaid	Black, Hispanic, undocumented immigrants	No (Diabetes grant)	1	5
4	Rural/suburban	Mix of insurance	Black, White	Yes (Linkages)	1	2
5	Urban/suburban	Medicaid	Black	Yes (Pathways, Linkages)	1	4

SIM = State Innovation Model.
Note: Geographic setting, dominant population served, and demonstration program participation were self-reported by administrator and supplemented by site visits.
↵a Several state programs promoting social needs screening were implemented during the study period, including the Linking Clinical Care with Community Supports (Linkages) project, the Michigan Pathways to Better Health (Pathways), and the State Innovation Model (SIM), as described under “Context and Setting” in Supplemental Appendix 1, available at https://www.AnnFamMed.org/content/19/4/xxx/suppl/DC1/.

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Table 2.

Comparison of Screening Practices Across FQHC Sites: Key Findings From Theme 1

Subthemes	Site 1	Site 2	Site 3	Site 4	Site 5
Identification of patients	Targeted rollout Started with Medicaid patients as a pilot program Layers of screening—in which all care team members were encouraged to perform social needs screening with patients at any point of contact.	All patients, starting with new patient appointment Screening conducted by telephone with CHW, in person by case/care management RNs, and medical providers	Targeted rollout Started with patients enrolled in specific programs at their first new patient appointment Sometimes medical team would ask for resources for patients not part of targeted rollout	All patients, starting with new patient appointment	Targeted rollout Started with patients aged 18 years and older, those referred by physicians, and patients with high ED utilization Expanded to behavioral health, prenatal visits Front desk distributed screening to all new patients and patients with health care maintenance exams
Team members performing screening	Front desk at initial new patient appointment CHW, case/care managers as needed Layers of screening	CHW by telephone before first new patient appointment Case/care managers, mental health referral as needed Layers of screening	CHW Case/care managers as needed	MAs, CHWs Layers of screening	CWH initially Added MAs and case/care managers as screeners Layers of screening
Screening approach	Standardized	Standardized Tailored to population (eg, younger, older)	Standardized Adaptations for specific communities (eg, Black, Hispanic)	Standardized	Standardized
Screening tool	PRAPARE initially, then moved to screening tool from the Northern Physicians Organization (as part of SIM)	PRAPARE	Internally developed	PRAPARE (internally customized)	PRAPARE
Mode of screening	Paper, plan to embed via NextGen/iPad Patient fills out the paper, hands it back to staff, then sent to CHW who follows up afterward	Embedded in EHR Questions asked verbally by staff, then entered into EHR	Paper, then scanned into EHR Moving to PRAPARE tool, embedded in EHR	Paper, then manually entered into EHR Moving to Next-Gen/NextPen to be fully integrated	Embedded in EHR
Role linking patient to resources	CHW, case/care manager	CHW	CHW	CHW	CHW

CHW = community health worker; ED = emergency department; EHR = electronic health records; FQHC = Federally Qualified Health Center; MA = medical assistant; NextGen = EHR product (NextGen Healthcare Inc); NextPen = EHR product that captures patient data by digital pen (NextGen Healthcare Inc); PRAPARE = Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences; RN = registered nurse; SIM = State Innovation Model program.

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Supplemental Appendices 1 and 2, and Supplemental Table 1

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The Article in Brief

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

Margaret Greenwood-Ericksen , and colleagues

Background Addressing patients’ health-related social needs, like housing and food security, is integral to patient care. Federally Qualified Health Centers (FQHCs) are leaders in screening for and addressing patients’ health-related social needs. However, screening practices vary. This variation is relatively unexplored, particularly with regards to organizational and state policy influences. Study authors conducted in-person, qualitative interviews at Michigan FQHCs to examine how screening approaches vary in the context of statewide social needs screening initiatives and structural factors.

What This Study Found Researchers identified four themes: 1) Statewide initiatives and local leadership drove variation in screening practices. 2) Community health workers played an integral role in identifying patients’ needs and their roles often shifted from “screener” to “implementer.” 3) Social needs screening data was variably integrated into electronic health records and infrequently used for population health management and 4) Sites experienced barriers to social needs screening that limited their perceived impact and sustainability.

Implications

FQHCs placed value on the role of community health workers, on sustainable initiatives, and on funding to support continued social needs screening in primary care settings. Determining the optimal approaches to screening is important to advancing community health.