health disparities

Most FQHCs Screen for Social Risks, but Disparities Remain

A new study has found that 29 percent of federally qualified health centers in the US do not have tools to screen for social risks such as food insecurity or housing instability, highlighting the need for targeted federal support of smaller centers, particularly those located in the South.

Federally qualified health centers (FQHCs), which provide critical primary care services to nearly 30 million low-income patients throughout the US, are in a unique position to reduce the social risks that many of their patients experience, including food insecurity, housing instability, and limited access to transportation and healthcare. For the first time, in 2019, the Health Resources and Services Administration (HRSA) collected national data on FQHCs’ social risk screening capabilities, but, until now, no national study has assessed this data to quantify national screening adoption rates and determine whether there are disparities in screening capabilities from state to state.

Now, a new study led by a School of Public Health researcher evaluated this data and found that while the majority of FQHCs do have social risk screening capabilities, there are regional disparities in these screening capabilities.

Published online ahead of print in the American Journal of Preventive Medicine, the study found that 71 percent of FQHCs collected social risk data in 2019, with more widespread collection by FQHCs located in the Northeast than in the South. The findings showed that the 29 percent of FQHCs that did not collect this data served fewer total patients, were less likely to be located in a state with a Medicaid accountable care organization, and were more likely to have a contract with a Medicaid managed care organization (MCO), health insurance plans that provide comprehensive benefits to Medicaid enrollees.

“FQHCs have been national leaders in screening patients for social risks, where we find that nearly 3 out of every 4 FQHCs collected patient social risk data,” says study lead and corresponding author Megan Cole Brahim, assistant professor of health law, policy & management. “This widespread implementation is really encouraging, as it means that most FQHCs have taken the first step to addressing the unmet social needs of patients, which could in turn improve health outcomes. However, lower adoption rates in smaller or southern FQHCs could also contribute to disparities in linkage to important social services.”

For the study, Cole and colleagues analyzed 2019 data from HRSA on FQHC organizational features, as well as patient sociodemographic characteristics, quality of care, and service utilization. The sample data represented every FQHC in the US.

Among the FQHCs that collected social risk data, the most common screening tool (used by 43 percent of FQHCs) was the Protocol for Responding to and Assessing Patients’ Assets Risks and Experiences screener, while 22 percent of FQHCs that screened for social risks did not use a standardized screener at all. Using non-standardized screeners could limit FQHCs’ ability to gather and share data with other practices or providers, as well as impact the risks that are assessed and addressed, the researchers say.

The variation in FQHCs’ screening capabilities among states ranged from 100 percent adoption in eastern states such as Connecticut, Rhode Island, and Delaware, to 42 percent in Maryland, 33 percent adoption in Wyoming, and 20 percent in South Dakota.

The smallest FQHCs were 14.3 percentage points less likely to screen for social risks than the largest FQHCs, perhaps due to fewer resources to implement these tools. The findings also showed that FQHCs located in a state with an active Medicaid accountable care organization (ACO) were 15.2 percentage points more likely to conduct social risk screening. FQHCs that participated in a Medicaid managed care contract were 9.5 percentage points less likely to screen for social risks than FQHCs without Medicaid managed care, after adjusting for other characteristics.

 “State-initiated implementation of comprehensive Medicaid ACO models may be one vehicle for increasing patient social risk screening at smaller FQHCs and elsewhere,” Cole says. However, since states with Medicaid ACOs already tend to invest more in social safety-net supports, she says, requiring Medicaid MCOs or their providers to collect these data could also help expand social risk screening. “This could help address existing disparities in social risk data collection, given that nearly 70 percent of Medicaid enrollees across the US are enrolled in MCOs.”

Ultimately, while having social risk screening capabilities is an important first step in addressing the needs of patients, Cole cautions that the assessments of FQHC screening capabilities do not capture the percentage of FQHC patients who have actually been screened.

“Social risk screening capabilities are necessary, but certainly not sufficient, in adequately screening for and in turn addressing the social needs of patients,” she says. “It’s important that future research quantifies the extent to which FQHC patients are screened and ultimately, better explores if and how screening for social risks in healthcare settings like FQHCs can improve health outcomes and equity.”