Screening for Social Risk at Federally Qualified Health Centers: A National Study

Published:February 07, 2022DOI:


      Federally Qualified Health Centers serve 29.8 million low-income patients across the U.S., many of whom have unaddressed social risks. In 2019, for the first time, data on social risk screening capabilities were collected from every U.S. Federally Qualified Health Center. The objectives of this study were to describe the national rates of social risk screening capabilities across Federally Qualified Health Centers, identify organizational predictors of screening, and assess between-state heterogeneity.


      Using a 100% sample of U.S. Federally Qualified Health Centers (N=1,384, representing 29.8 million patients) from the 2019 Uniform Data System, the primary outcome was whether a Federally Qualified Health Center collected data on patients’ social risk factors (yes/no). Summary statistics on the rates of social risk screening capabilities were generated in aggregate and by state. Linear probability models were then used to estimate the relationship between the probability of social risk screening and 7 key Federally Qualified Health Center characteristics (e.g., Federally Qualified Health Center size, Medicaid MCO contract, Medicaid accountable care organization presence). Data were analyzed in 2020‒2021.


      Most (71%) Federally Qualified Health Centers collected social risk data, with a between-state variation. The most common screener was the Protocol for Responding to and Assessing Patients’ Assets Risks and Experiences (43% of Federally Qualified Health Centers that screened), whereas 22% collected social risk data using a nonstandardized screener. After adjusting for other characteristics, Federally Qualified Health Centers with social risk screening capabilities served more total patients, were more likely to be located in a state with a Medicaid accountable care organization, and were less likely to have an MCO contract.


      There has been widespread adoption of social risk screening tools across U.S. Federally Qualified Health Centers, but between-state disparities exist. Targeting social risk screening resources to smaller Federally Qualified Health Centers may increase the adoption of screening tools.
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        • Cole MB
        • Nguyen KH.
        Unmet social needs among low-income adults in the United States: associations with health care access and quality.
        Health Serv Res. 2020; 55: 873-882
        • Kushel MB
        • Gupta R
        • Gee L
        • Haas JS.
        Housing instability and food insecurity as barriers to health care among low-income Americans.
        J Gen Intern Med. 2006; 21: 71-77
        • Berkowitz SA
        • Hulberg AC
        • Hong C
        • et al.
        Addressing basic resource needs to improve primary care quality: a community collaboration programme.
        BMJ Qual Saf. 2016; 25: 164-172
      1. Health Center Program: impact and growth. Health Resources & Service Administration. Updated 2020. Accessed September 24, 2020.

        • De Marchis E
        • Pantell M
        • Fichtenberg C
        • Gottlieb LM.
        Prevalence of patient-reported social risk factors and receipt of assistance in federally funded health centers.
        J Gen Intern Med. 2020; 35: 360-364
        • Baggett TP
        • Berkowitz SA
        • Fung V
        • Gaeta JM.
        Prevalence of housing problems among community health center patients.
        JAMA. 2018; 319: 717-719
      2. 42 USC 254b: Health Centers. Accessed July 21, 2021.

        • Yue D
        • Pourat N
        • Chen X
        • et al.
        Enabling services improve access to care, preventive services, and satisfaction among health center patients.
        Health Aff (Millwood). 2019; 38: 1468-1474
        • Nguyen KH
        • Trivedi AN
        • Cole MB.
        Receipt of social needs assistance and health center patient experience of care.
        Am J Prev Med. 2021; 60: e139-e147
        • Kranz AM
        • Mahmud A
        • Agniel D
        • Damberg C
        • Timbie JW.
        Provision of social services and health care quality in U.S. community health centers, 2017.
        Am J Public Health. 2020; 110: 567-573
        • Gottlieb L
        • Sandel M
        • Adler NE.
        Collecting and applying data on social determinants of health in health care settings.
        JAMA Intern Med. 2013; 173: 1017-1020
        • Andermann A.
        Screening for social determinants of health in clinical care: moving from the margins to the mainstream.
        Public Health Rev. 2018; 39: 19
        • Fraze TK
        • Brewster AL
        • Lewis VA
        • Beidler LB
        • Murray GF
        • Colla CH.
        Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by us physician practices and hospitals.
        JAMA Netw Open. 2019; 2e1911514
        • The National Academies of Sciences Engineering Medicine
        Integrating social needs care into the delivery of health care to improve the Nation's health.
        The National Academies of Sciences Engineering Medicine, Washington, DC2019 ( Published 2019. Accessed July 29, 2021)
        • Brewster AL
        • Fraze TK
        • Gottlieb LM
        • Frehn J
        • Murray GF
        • Lewis VA.
        The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by U.S. physicians.
        Milbank Q. 2020; 98: 1114-1133
        • Lewis VA
        • Spivack S
        • Murray GF
        • Rodriguez HP.
        FQHC designation and safety net patient revenue associated with primary care practice capabilities for access and quality.
        J Gen Intern Med. 2021; 36: 2922-2928
        • Gold R
        • Bunce A
        • Cowburn S
        • et al.
        Adoption of social determinants of health EHR tools by community health centers.
        Ann Fam Med. 2018; 16: 399-407
        • LaForge K
        • Gold R
        • Cottrell E
        • et al.
        How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview.
        J Ambul Care Manage. 2018; 41: 2-14
        • Gottlieb LM
        • Tirozzi KJ
        • Manchanda R
        • Burns AR
        • Sandel MT.
        Moving electronic medical records upstream: incorporating social determinants of health.
        Am J Prev Med. 2015; 48: 215-218
        • Cantor MN
        • Thorpe L.
        Integrating data on social determinants of health into electronic health records.
        Health Aff (Millwood). 2018; 37: 585-590
        • Gruß I
        • Bunce A
        • Davis J
        • Dambrun K
        • Cottrell E
        • Gold R.
        Initiating and implementing social determinants of health data collection in community health centers.
        Popul Health Manag. 2021; 24: 52-58
        • Byhoff E
        • Cohen AJ
        • Hamati MC
        • Tatko J
        • Davis MM
        • Tipirneni R.
        Screening for social determinants of health in Michigan health centers.
        J Am Board Fam Med. 2017; 30: 418-427
        • Palakshappa D
        • Scheerer M
        • Semelka CTA
        • Foley KL.
        Screening for social determinants of health in free and charitable clinics in North Carolina.
        J Health Care Poor Underserved. 2020; 31: 382-397
        • Weir RC
        • Proser M
        • Jester M
        • Li V
        • Hood-Ronick CM
        • Gurewich D.
        Collecting social determinants of health data in the clinical setting: findings from national PRAPARE implementation.
        J Health Care Poor Underserved. 2020; 31: 1018-1035
      3. PRAPARE. National Association of Community Health Centers. Updated 2020. Accessed July 21, 2021.

      4. Uniform Data System (UDS) resources. Health Resources and Services Administration, Bureau of Primary Health Care. Updated 2021. Accessed July 21, 2021.

        • Gifford K
        • Ellis E
        • Lashbrook A
        • et al.
        A View from the states: key Medicaid policy changes: results from a 50-state Medicaid budget survey for state fiscal years 2019 and 2020.
        Kaiser Family Foundation, San Francisco, CA2019 ( Published October 18, 2019. Accessed July 21, 2021)
        • Samuels-Kalow ME
        • Boggs KM
        • Cash RE
        • et al.
        Screening for health-related social needs of emergency department patients.
        Ann Emerg Med. 2021; 77: 62-68
        • Strategies Center for Health Care
        Screening for social determinants of health in populations with complex needs: implementation considerations.
        Center for Health Care Strategies, Hamilton, NJ2017 ( Published October 26, 2017. Accessed July 21, 2021)
        • Davidson KW
        • McGinn T.
        Screening for social determinants of health: the known and unknown.
        JAMA. 2019; 322: 1037-1038
        • Browne J
        • Mccurley JL
        • Fung V
        • Levy DE
        • Clark CR
        • Thorndike AN.
        Addressing social determinants of health identified by systematic screening in a Medicaid accountable care organization: a qualitative study.
        J Prim Care Community Health. 2021; 122150132721993651
        • Bradley EH
        • Canavan M
        • Rogan E
        • et al.
        Variation in health outcomes: the role of spending on social services, public health, and health care, 2000–09.
        Health Aff (Millwood). 2016; 35: 760-768
        • Centers of Medicare and Medicaid Services
        CMS issues new road map for states to address the social determinants of health to improve outcomes, lower costs, support state value-based care strategies.
        Centers of Medicare and Medicaid Services, Baltimore, MD2021 ( Published January 7, 2021. Accessed July 21, 2021)
        • Tobin-Tyler E
        • Ahmad B
        Marrying value-based payment and the social determinants of health through Medicaid ACOs: implications for policy and practice.
        Milbank Memorial Fund, 2020 (May 2020. Accessed July 21, 2012)
        • Byhoff E
        • Freund KM
        • Garg A.
        Accelerating the implementation of social determinants of health interventions in internal medicine.
        J Gen Intern Med. 2018; 33: 223-225
        • Gold R
        • Gottlieb L.
        National data on social risk screening underscore the need for implementation research.
        JAMA Netw Open. 2019; 2e1911513
        • Murray GF
        • Rodriguez HP
        • Lewis VA.
        Upstream with a small paddle: how ACOs are working against the current to meet patients’ social needs.
        Health Aff (Millwood). 2020; 39: 199-206
        • Cartier Y
        • Gottlieb L.
        The prevalence of social care in US health care settings depends on how and whom you ask.
        BMC Health Serv Res. 2020; 20: 481
        • Krist AH
        • Davidson KW
        • Ngo-Metzger Q.
        What evidence do we need before recommending routine screening for social determinants of health?.
        Am Fam Physician. 2019; 99: 602-605
        Date accessed: July 22, 2021
        • LeavittPartners
        Social determinants matter, but who is responsible?.
        Cottonwood Heights, UT, 2018 (Leavitt Partners. Published May 9, 2018. Accessed July 22, 2021)
        • Abir M
        • Hammond S
        • Iovan S
        • Lantz PM.
        Why more evidence is needed on the effectiveness of screening for social needs among high-use patients in acute care settings.
        Health Affairs Blog. 2019; (May 23, 2019)
        • Berkowitz SA
        • Basu S.
        Unemployment insurance, health-related social needs, health care access, and mental health during the COVID-19 pandemic.
        JAMA Intern Med. 2021; 181: 699-702
        • Niles MT
        • Bertmann F
        • Belarmino EH
        • Wentworth T
        • Biehl E
        • Neff R.
        The early food insecurity impacts of COVID-19.
        Nutrients. 2020; 12: 2096
        • Sandhu S
        • Lemmon ME
        • Eisenson H
        • Crowder C
        • Bettger JP.
        Addressing the social determinants of health during the COVID-19 pandemic: ensuring equity, quality, and sustainability.
        Fam Community Health. 2021; 44: 78-80