How High-Performing Community Health Clinics Accomplish Social Risk Screening

Sara L. Ackerman; Holly Wing; Maura Pisciotta; Danielle Hessler Jones; Laura M. Gottlieb

doi:10.3122/jabfm.2025.250123R3

Article Figures & Data

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Table 1.

Participating Clinics and Staff

Clinic ID	State	Total Adult Patients during Study Period	Average Screening Rate per 100 Adult Encounters (2021)	Average Screening Rate per 100 Adult Encounters (2022)	Number of Interviews (N)
1	Massachusetts	4633 (2021)	70	75	1 Clinician
		5063 (2022)			2 Frontline staff
					2 Leadership
2	Wisconsin	4158 (2021)	26	37	1 Clinician
		4178 (2022)			1 Frontline staff
					3 Leadership
3	California	3737 (2021)	29	31	2 Frontline staff
		4245 (2022)			3 Leadership
4	Massachusetts	2914 (2021)	22	27	4 Frontline staff
		2453 (2022)			1 Leadership
5	Massachusetts	3623 (2021)	19	20	1 Clinician
		5598 (2022)			3 Frontline staff
					3 Leadership

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Table 2.

Participant Characteristics

Clinic Role	Description	Number of Interviews (N)
Administrative leader	Chief executive officers, chief operating officers, quality improvement directors, team leads, clinician leaders, and individuals familiar with social risk screening at participating clinic and how screening and referrals were incorporated into practice.	12
Clinician	Physicians and advanced practice clinicians involved in social risk screening/referral and have no administrative leadership role.	3
Frontline staff	Clinical managers, medical assistants, community health workers, care coordinators, patient navigators, social workers, nurse case managers and registration staff.	12

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Table 3.

Exemplar Quotes

Themes	Quotations
Clinics invested in team-based care	“We’ve been able to implement this more easily because we know who the front desk people are and they’re our friends and colleagues, and we can troubleshoot things in real time.” [Clinician Leader, Clinic 4]
	“I do think that the culture for the medical assistants (MAs) here has been really empowering… […] …they've given them this ownership of, we need you guys to do the screenings. And you can tell. They take pride in making sure they're getting the screenings done. […] the MAs really are valued participants of care here…” (Clinician, Clinic 1)
	“…anything that we try new… […] …everybody sits down with MAs, nurses, providers. […] We have a good teamwork, starting from the front desk to the end of the care coordinator. (MA, Clinic 4)
	“So everyone's input and their opinion is heard.” (Registration staff, Clinic 4)
	“And I'm so happy because I have such an amazing team. We work so close together…once we do something we're like, ‘Okay, what's the next step to this thing?’” (Administrative Leader, Clinic 1)
Clinics engaged in sustained quality improvement	“…we do a plan-do study act, is what we call it, lots of folks call it, just our typical quality improvement (QI) action. So we did all of our planning for those last four months…next week we'll pull the big group back together again and talk about how's it going, what's working, what isn't working… We have draft standard operating procedures (SOPs). And then at the end of that, hopefully about four months from now, we'll finalize all those draft SOPs and say, okay, go.” (Administrative Leader, Clinic 2)
	“The way the EHR works is that if it [social risk screening] hasn't been done in the previous 12 months, we added it to what's called our health maintenance…it pops up and gives an alert saying that the patient is due for that item.” (Administrative Leader, Clinic 3)
	“Well, before we go into the patient, if I click on the patient's chart, the popup comes up first because they need an SDOH [social determinants of health screening].” (MA, Clinic 4)
	“The teams are being asked to do a daily quality metric and set a goal and either have a red sticker if you didn't meet the goal that day or a green sticker…I think some teams have done SDH screening as a quality metric that they're following on a daily basis.” (Administrative Leader, Clinic 4)
	“So we do show that performance every month to the MAs, how our overall health center performance is performing, and then their individual performance, mainly just to see [if] they encounter any barriers…” (Administrative Leader, Clinic 1)
Link between SR screening efforts and availability of resources for patients	“I have to say, if you don’t have the resource at all, I would hold myself from asking…at the same time, if the resource does not exist I don’t want to say let’s not ask…I think asking the question and getting the data that we can then demonstrate to the state and the funders, ‘Hey, this is a need…’” (Administrative Leader, Clinic 5)
	“I think for us it's helpful to only ask the questions we can address. I think we would maybe get pushback or maybe a negative response if we were asking something that we couldn't help with. Like, maybe we were just being nosy.” (Care Coordinator, Clinic 2)
*Primary Care Medical Home certification requirements*	“I think [patient-centered medical home certification] it was a huge motivator. It was a really big project to get recognized, so the whole clinic was knowing that change was coming in regards to getting PCMH recognized. So, it was just a time of change in the clinic, and it worked out that people were willing to do the screenings.” (Administrative Leader, Clinic 2)
	“And the other thing is we're a patient centered medical home certified. So they make sure too, that we're doing it, the screenings. They look at certain charts to make sure that the screening is done and the follow up as well.” (Nursing Director, Clinic 1)
ACO incentives and requirements	“…right now the SDOH is a quality measure that the accountable care organization (ACO) looks at…we get money if we screen a certain percentage of people. (Administrative Leader, Clinic 4)
	“ACO community health workers (CHWs) that focused on care management, they are tied to only be able to work with patients who have [type of health insurance]. So we were like, ‘As an organization, we cannot turn a patient away and say, “I'm sorry, I'm not going to give you resources, because you don't have the insurance or the eligibility.'” […] So regardless of the eligibility position for the patient, we will help the patient.” (Administrative Leader, Clinic 5)
	“…SDOH is one of [the ACO] measures that we have to perform at a certain level, that's only for ACO patients.” (Administrative Leader, Clinic 1)
Support from participation in CHC consortia	“It's been huge in the sense that we were part of this SDOH work group with [name of health plan] and they're really just having us come together, and even though the majority of the other health centers are not on the same EHR, our health record, we have been able to…hear out what are other people doing, what might be best practices as far as screening…” (Administrative Leader, Clinic 3)
*Support from external funding*	“…our research and population health department is a grant-funded entity… It includes everything from our navigators…to community health workers, to our researchers, our pop health coordinators, our QI team, and a bunch of others.” (Administrative Leader, Clinic 5)
	“I believe we got a grant a little bit over a year ago. So that's why we're still working on implementing, on making sure that we're doing the right thing. So we're working on having a good workflow basically on this position.
	Interviewer: And is the grant specifically for a CHW to help with patients' social needs, like housing and food?
	Participant: Yes.” (CHW, Clinic 3)
	“There used to be quality dollars that were tied to the frequency of us asking those questions. Those dollars are no longer specified in that way. Instead, they go to a larger pool of grant dollars that we get. So I think that's where it started, was the financial gain.” (Administrative Leader, Clinic 2)
	“We hope to utilize the screenings to be able to have data to apply for grants. […] It's a very well-encompassing form of data to let grant funders know that these are the struggles that our patient population deals with.” (Administrative Leader, Clinic 2)

Abbreviations: ACO, Accountable Care Organization; CHC, community health center; CHW, Community Health Worker; SDOH, Social Determinants of Health; SR, social risk.