Assessing and addressing the social determinants of health in community health centers and other community settings

Federally-Qualified Health Centers (FQHCs) are community-directed organizations that serve over 22 million people largely in medically underserved populations that confront social determinants of health (SDH).  Current medical acuity does not capture these non-clinical factors that affect health.  FQHCs need data to identify which non-clinical services are most needed for their patients and to form partnerships with public health and community organizations. 

To address this need, the National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, and Institute for Alternative Futures created a standardized patient risk assessment tool focused on the SDH.  Using the County Health Rankings as a framework, the partners developed a paper-based tool that is free for any interested provider and are now creating an open access Electronic Health Record template.  To determine which SDH domains and measures to include in the tool, the partners reviewed the literature, assessed existing health risk assessment tools, engaged diverse stakeholders, and sought feedback from an advisory group of experts.  

This presentation will present the tool, how it was developed, and how it can be used by any provider organization to better understand and manage their patient populations.  The tool’s potential long term impact will also be discussed, such as using standardized data to advocate for policy changes that address the SDH, test the impact of population-based interventions, and ensure adequate payment that provides fair compensation for caring for at-risk patients and that more fully supports the integration of clinical and non-clinical care.