SDoH Screening and Care Navigation

FQHCs operating under HRSA UDS reporting requirements collect SDoH data as part of the clinical encounter. The infrastructure for that collection — standardized screening tools, care coordination workflows, community resource directories — exists in most FQHCs in some form. The problem is that screening happens at the point of care, which means it only captures patients who make it to the clinic.

For FQHC patient populations where social barriers are among the primary reasons patients do not make it to the clinic, a screening process that only operates at the visit misses the patients with the highest social need. The patient who has not been in for six months because transportation is not available, who does not call because phone access is limited, who did not fill their prescription because the cost was not manageable — that patient's SDoH needs are not captured in the clinical encounter because the clinical encounter did not happen.

Integrating SDoH identification into outreach interactions — the chronic care management check-in, the appointment reminder call, the post-discharge follow-up — allows the FQHC to capture social barriers at the moments when patients are engaged, not just when they are present. And it creates the infrastructure to route those barriers to a community resource or care navigator in the same interaction, rather than generating a referral that the patient may or may not follow.

The SDoH Determination Agent identifies social barriers during existing outreach interactions — chronic care management check-ins, appointment confirmation calls, post-discharge follow-up — capturing transportation barriers, food insecurity, housing instability, and language access needs in a structured format that is integrated with the clinical record.

When a social barrier is identified, the agent routes to the appropriate community resource or care navigator in the same interaction. A patient who discloses a transportation barrier during their monthly chronic care check-in receives the routing to the transportation assistance program before the call ends. A patient who discloses food insecurity during a post-discharge follow-up is connected to the food bank referral workflow at the point of disclosure.

For FQHCs reporting HRSA UDS SDoH screening rates and tracking the connection between social needs and clinical outcomes, the change is in how many patient interactions include structured SDoH data — not just the patients who arrived for a visit. For care teams, the change is in receiving SDoH information with clinical context already attached, rather than discovering social barriers for the first time when a patient presents with an acute issue that the barrier contributed to.