How High-Performing Community Health Clinics Accomplish Social Risk Screening

Clinics Invested in Team-Based Care

All participating clinics operated with “team-based care” models, in which patient-care responsibilities are shared among clinicians, medical assistants (MAs), social workers, and other clinic staff. At some clinics, front desk staff participated in team meetings alongside clinicians and MAs. Interviewees reported that care teams met regularly to discuss both individual patients and practice change initiatives. SR screening was frequently discussed in care team meetings, with topics including the appropriate time and place for screening, strategies to ensure that screening did not interfere with other clinical activities, and how to integrate SR screening with efforts to respond to patient-reported hardships. A physician and several MAs from one clinic reported that the participation of front desk staff in team meetings had enabled robust discussions about how to mitigate SR screening implementation barriers. Subsequent practice changes had contributed to consistent uptake of SR screening by front desk staff, whose perspectives were described as being “ingrained in [the clinic’s] team culture…” (physician, Clinic 4).

Approaching social care as a collective, team-based activity was evident in clinics’ approach to SR screening. Across participating clinics, responsibility for implementing SR screening was distributed among multiple members of a given care team, rather than being delegated by leadership to staff in particular roles, for example, MAs. “It is not necessarily from the top down, it is just the whole entire organization” (quality improvement coordinator, Clinic 3), said one participant. Another participant from the same CHC confirmed that implementing SR screening was a team endeavor: “…everybody’s really aligned with it and sees the importance” (administrative leader, Clinic 3). This embrace of collaborative work was apparent in the social dynamics we observed during an interview with 3 staff from 1 clinic. In addition notable was the considerable variability across clinics in how and by whom SR screening was conducted during a patient’s path through the clinic. The successful integration of screening appeared to hinge on the teams’ ability to adapt screening workflows to clinic conditions and patient and staff preferences, rather than their ability to adopt standardized procedures and roles. (See Table 3 for additional quotes illustrating how an emphasis on team-based care contributed to SR screening uptake.)

Though MAs were not solely responsible for social risk screening in most clinics, they nonetheless played a central role in multiple aspects of social care. At several clinics, MAs were involved in decisions about SR screening implementation, including contributing to workflow revisions when screening rates flagged. At one clinic, MAs combined screening with direct assistance to patients, for example, providing information about local resources or making referrals to social workers or community health workers (CHWs). “We have a list of different grocery places that give out free groceries for people in need…,” said an MA (Clinic 4). Giving MAs responsibility for SR screening and follow-up was often described as “empowering” both because it gave MAs a sense of “ownership” and pride and made them feel that the organization valued their work.

At clinics with less of an emphasis on MA involvement in social care decisions, care teams nonetheless served as an important mechanism for ensuring accountability with screening targets: “…we have huddle every morning…[the program lead] has told the MAs, ‘Hey, you need to be asking those questions again.’” (clinician, Clinic 2)

Clinics Engaged in Sustained Quality Improvement

Efforts to implement SR screening were also buoyed by organization-level QI efforts. These high performing clinics were already using QI activities to improve care across a range of clinic initiatives. They then harnessed that capacity to support social care practices, engaging in “plan-do-study-act cycles” aimed at improving SR screening rates. For example, all the clinics used screening data as a form of health center-, group- and individual-level performance feedback. Communicating performance metrics on a regular basis functioned as a type of report card or at least a means of initiating conversations among leaders and staff about reasons for lower-than-expected SR screening rates and strategies for improvement. Screening data were also used to prompt discussions about discrepancies in SR screening activities and screening rates represented in clinic records. For example, a [QI director] said: “…if the MA says, ‘Oh, well, we are asking everybody about this, but the numbers are not showing.’ It clearly means that there's a workflow issue, then we have to address it. That is where I come in.” (Clinic 3)

Social care-focused QI activities varied across settings. For example, staff feedback about patient outreach regularly led to adjustments to screening workflows at one clinic. At another, EHR alerts were employed to indicate to providers when a patient was due for SR screening. Across all participating clinics, both QI and care team commitments helped sustain attention to SR screening among busy providers and staff in a context of multiple competing demands. These structures and processes reinforced an ethos of mutual support and accountability, such that striving to improve screening rates became part of a group effort to support the clinic’s mission and maintain staff cohesion. (See Table 3 for additional quotes illustrating how QI practices contributed to SR screening uptake.)

Commitment to Screening Was Often Linked to Clinics’ Capacity to Facilitate Access to Social Services for Patients in Need

Numerous interviewees across participating clinics reported that staff support for SR screening was contingent on the clinic’s ability to help patients with an identified social need, whether by directly providing assistance or by making referrals to community services. Some participants put this in stark terms, indicating that asking patients questions about their social risks felt like a form of moral injury to both patients and providers if a clinic does not have the capacity to provide assistance: “It does not do any good to ask somebody if they are food insecure, if you are not going to offer them resources to help meet that need. It just feels kind of hollow and empty,” said an administrative leader at Clinic 3. This participant explained that she had previously worked at clinics where staff were screening patients, or “checking the box,” without addressing identified social needs. By contrast, she felt that Clinic 3 was more meaningfully addressing the “missing piece of the puzzle.” “That is the whole purpose” of social care, she said. A contrasting perspective was voiced by one interviewee, who indicated that asking about social needs, even in the absence of services, would produce data that could serve as an important advocacy tool with funders. Implicit in these discussions was the understanding that social care, like clinical care, is most effective when it involves comprehensive and coordinated services.

To mitigate staff concerns about potential harms resulting from asking about difficult life circumstances without the capacity to help, several participating clinics had adjusted standardized SR screening forms to include only questions pertaining to social risks that team members felt could be addressed by the clinic. “We want to be able to have resources in place if we’re asking them,” said one clinic leader (Clinic 2). On the other hand, one interviewee in our study sample reported that it felt useful to ask patients about all SRs even if clinic staff are not able to provide social services immediately. Resources to address the identified need may become available later, said that participant, such that “…not asking is missing that opportunity to get something that we might not know (care coordinator, Clinic 4).”

Most participants agreed that the primary goal of SR screening is connecting patients with services. To bolster their social care efforts, and ensure that SR screening led to meaningful assistance and referrals to local organizations, all the participating clinics had actively sought – and often secured – external funding to support their capacity to refer patients to community services and/or provide direct assistance, for example, clothing, transportation, and food.

Accountable Care Organization Requirements and Incentives Influenced Screening

Most participating CHCs were members of ACOs, which are groups of health care providers and organizations that collectively agree to be held financially accountable for the quality of clinic services provided. Three of the 5 participating clinics reported being members of ACOs that prioritized social care. ACO financial incentives rewarded clinics for reaching predetermined SR screening benchmarks, and peer institutions within ACOs provided mutual aid: “We share experiences with each other within [the] ACO…whenever we talk, I feel like a lot of clinics [are] try[ing] to move to doing the screenings more often than once a year.” (population health manager, Clinic 1)

Despite its largely positive influence, ACO participation could be a source of tension. ACO financial incentives for screening applied only to patients with select insurance coverage. This forced clinics to choose between sorting patients into screen/do not screen categories or screening all patients while only receiving financial incentives for a subset.

Primary Care Medical Home Certification Requirements Motivated Screening

Staff at 2 participating clinics reported that their CHC was certified as a PCMH. To meet certification requirements, clinics are expected to achieve both required and elective criteria; SR screening was one of the elective criteria selected by one clinic. A patient care coordinator at that clinic described the PCMH certification process as a “huge motivator” to integrate SR screening into clinic workflows (see Table 3 for full quote). (Clinic 2)

Support from CHC Consortia, Grants, and External Partnerships Was Influential

Interviewees at 4 of the participating clinics indicated that their organization was a member of a state-wide CHC consortium. The consortia provide a forum for troubleshooting challenges with SR screening, learning about the social care activities at other CHCs, and “getting feedback not only from health centers, but also other community organizations and ideas of how to better reach and connect to folks…” (administrative leader, Clinic 3).

Some clinics also received financial support from the CHC consortia and/or other external grants. Departments of public health and the US Health Resources and Services Administration were most often mentioned as sources of funding. These funds often enabled clinics to hire CHWs tasked with helping patients access community resources. An externally-funded CHW was able to serve “any patient, regardless of insurance coverage…”, a clinic leader told us (Clinic 5), thereby bridging the gap created by their ACO’s selective reimbursement criteria.