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.

Agents capture what patients report. Coordinators and community health workers arrange the help.

Screening results in one record. Social needs screenings from your EHR sit in each patient’s record, next to the clinical data.

Barriers come up in outreach. During check-ins and reminders, patients can report transportation, food, housing or cost problems.

A coordinator follows up. Reported barriers are routed to a coordinator or community health worker by rule.

The visit still happens. Once the barrier is handled, ZynSchedule books or moves the visit.

Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.