Our team engaged with two FQHCs in two of Arizona’s major urban areas to document their processes and policies around social risk screening with tools such as PRAPARE. The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a standardized, stakeholder developed tool to guide health care workers’ conversations around social risk with their patients. The CFIR framework was used to direct a process mapping exercise with staff at each FQHC to visually describe the workflow, gaps and opportunities for SDOH screening. Community participation in process mapping occurred in the setting of group workshops between our research team and a team of CHWs, clinical staff, and organizational leaders from each organization.

The two partnering FQHCs of this study generated professionally diverse and collaborative teams to unveil key areas for health system improvements within their own organizations. Improvements identified included clear channels for primary care to refer to CHWs after a PRAPARE screening, resolution of IT challenges in documenting PRAPARE screening, and a more universal system for community partner referral to ensure that CHWs can adequately assist patients in receiving services.

This practice-based study demonstrates the importance of primary care teams’ inclusion of CHWs to ensure a system that can fully identify and respond to the SDOH needs of patients. Working directly with clinic-based CHWs to refine social risk documentation is essential to effectively aid patients in resource access once social risk is identified. Further research should evaluate rates of social risk screening before and after process mapping to assess quality improvement.