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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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    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)
    SiteGeographic SettingPayer Type Serving PopulationDominant Population ServedParticipation in State Demonstration ProgramaAdministrators, No.Screeners/Implementers, No.
    1RuralMix of insuranceWhiteYes (Linkages, SIM)13
    2RuralMedicaidWhite, young families, older adultsYes (Linkages)14
    3UrbanMedicaidBlack, Hispanic, undocumented immigrantsNo (Diabetes grant)15
    4Rural/suburbanMix of insuranceBlack, WhiteYes (Linkages)12
    5Urban/suburbanMedicaidBlackYes (Pathways, Linkages)14
    • 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

    SubthemesSite 1Site 2Site 3Site 4Site 5
    Identification of patientsTargeted 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 appointmentTargeted 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 screeningFront 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 approachStandardizedStandardized
    Tailored to population (eg, younger, older)
    Standardized
    Adaptations for specific communities (eg, Black, Hispanic)
    StandardizedStandardized
    Screening toolPRAPARE initially, then moved to screening tool from the Northern Physicians Organization (as part of SIM)PRAPAREInternally developedPRAPARE (internally customized)PRAPARE
    Mode of screeningPaper, 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 resourcesCHW, case/care managerCHWCHWCHWCHW
    • 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.
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The Annals of Family Medicine: 19 (4)
The Annals of Family Medicine: 19 (4)
Vol. 19, Issue 4
1 Jul 2021
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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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