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The overall purpose of this qualitative study was to explore the variation in implementation of screening practices related to patients’ health-related social needs in federally qualified health centers (FQHC) in Michigan. Assessing social needs is essential because they can impact a patient’s ability to receive medical care and improve their health. The authors of the study stated the variation of screening practices is potentially due to geography, grants, state initiatives and community health worker (CHW) programs. This study delves into whether these factors impact the variation in screening practices.
The study was conducted in two phases. In the first phase, a survey regarding the screening forms and practices used was sent to 23 FQHCs. The differences in screening between sites was explored further in 3 subsequent focus groups. Themes were identified, which contributed to the format of the semi-structured, qualitative interviews in phase 2. Twenty-three interviews were done at the five of the FQHC sites participating in this phase. The interviews were transcribed and four research team members reviewed two transcripts and identified themes for the codebook which was used to code the rest of the interviews.
The authors identified 4 themes related to social needs screening across the FQHC sites through descriptive analysis. The 1st theme was Variation in Screening Practices – the authors described statewide initiatives and local leadership as contributing factors to variation in screening practices. Our journal club group recognized that the sites included in this study were only FQHCs located in rural, urban, rural/suburban, and urban/suburban geographic settings. Screening practices of for-profit hospitals and large healthcare systems were not obtained. Additionally, performing these screenings only at FQHCs can lead to a subjective process where assumptions may be made about Medicare and Medicaid patients as having more social needs. With many members of our group being part of our university’s Rural Medicine Program, we discussed the social determinants of health from a rural perspective such as lack of transportation and access to health care. Many patients in rural communities must travel long distances to receive health care. Social determinants of health are not only limited to rural areas, but also to suburban and urban areas. Therefore, as a group, we felt that screening practices of individual patients’ social needs in each of these areas is necessary to evaluate the data for each of these settings served. Assessment of these individual social needs can then be analyzed to identify population level needs.
The 2nd theme was the Shift in Community Health Worker (CHW) roles. As a group, we agreed that CHWs were an advantageous and critical component in implementing the screening process. We felt that patients would feel more comfortable going through the screening with a CHW as compared to a physician. Patients might feel more intimidated discussing social needs with a physician. Physicians may also have a limited amount of time to spend with a patient. CHWs can spend more time with patients and direct them to resources in the community. This is especially helpful when the CHWs are from the community and can relate to patients.
The 3rd theme was Variable Integration of Screening Data. Two sites had the screening embedded into the Electronic Health Record and three sites had paper screenings. Our group brought up concerns of inconsistent data entry and difficulty with synthesizing the data. The screening data in the study was mostly used to identify individual gaps for patients rather than tracking social needs trends across a population. Our group noted that not all rural clinics have screenings embedded into their Electronic Health Records. This could lead to difficulty with data analysis and ability to see patterns at a health system or population level. In the future, our group would recommend the use of these screenings to address social needs issues on a larger scale such as the level of the county health department or state. Our group also questioned whether CHW and other healthcare workers have time to discuss findings with one another.
The 4th theme was Barriers Limited Impact. Barriers to social needs screening included limited resources and staff availability which limit impact and sustainability. CHWs fulfill a variety of roles and oftentimes were pulled away from social needs screenings to attend to other tasks in the clinic. Additionally, administrators expressed concerns about funding to pay for CHWs. They are generally paid by non-clinical revenue and often cannot be billed for their work. Grants or organizational resources are used to pay them, which does not provide a sustainable support for these positions. To address these concerns, our group suggested finding ways to make the system more sustainable. For example, it was suggested that these hospitals and clinics could obtain state funding so that CHWs can be reimbursed through Medicare/Medicaid.
Our group discussed additional questions that could be addressed: 1) Social needs of individuals go beyond the doctor’s office. What are the perspectives of people who are unable to access care or do not regularly go to the doctor? Our group suggested conducting social needs screenings outside of clinics and hospitals to obtain these perspectives. 2) How can we effectively recruit and sustain community health workers? As a group, we agreed that they are crucial to the health care team and that health systems need to find ways to sustainably fund these positions. 3) Addressing social needs of patients should involve stakeholders such as administrators, executives, clinical staff, patients, and their families. Identifying these needs focuses on primary prevention and can potentially save hospitals money by avoiding re-admission or tertiary care. So how can we have these stakeholders be involved in forming screening practices? As future physicians, aspects of this article that we will use in practice include implementing social needs screening tools and incorporating community health workers into the interdisciplinary team to provide the best care for patients. By using individual data, we can assess the needs of communities and effectively provide them with the care they need.