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Two-Tiered Screening for Patient Socila Needs in a Safety-Net Setting
Using Two Pre-Screening Questions to assess patients’ social needs at a Chicago-area FQHC

Resource Topic: Social Determinants of Health (SDOH)

Resource Subtopic: Health Equity, Population Health.

Keywords: Access to Care, Appointments, Care Coordination, Community Engagement, Documentation, Education of - Staff (e.g., Competency-Based), Patient Education, Non-Clinical Services, Partnerships, Screening.

Year Developed: 2022

Resource Type: Template.

Primary Audience: Administrative Staff Enabling Staff Outreach Staff
Secondary Audience: C-Suite (CEOs, CFOs, CIO, COOs, CMOs, etc.) Clinicians

Language(s): English, Spanish

Sponsored by: Other

Developed by: Erie Family Health Centers (See other resources developed by this organization).

Resource Summary: Erie Family Health Centers, a Chicago-area Federally Qualified Health Center, initiated a two-part social needs screening process with patients in May 2020. A medical assistant asked a single prescreening question about interest in being connected to resources and interested patients received a follow-up call from staff to screen for needs and connect with resources. A second prescreening question was added asking patients their preferred method for receiving resources. The results of this process suggest that a two-tiered screening for social needs is feasible in the safety net setting.

Resource Details: The follow up questionnaire assesses eight categories of need including: income, housing, food, medications, childcare supplies, coping, transportation, and any “other” needs. The questions were originally derived from Thrive, Health Leads, PRAPARE, Medical Expenditure Panel Survey, and OECD Measuring Financial Literacy Tools and since creation have undergone numerous revisions based on input from patients and staff. The evolution of the program from a one to two-question prescreener reduced the volume of calls, allows staff to contact patients faster, and gives patients choice how to disclose and receive information (phone, email, or text). Allowing for identification of specific needs permitted the health center to address patient requests more effectively with 74% of patients successfully contacted receiving resource linkage via their preferred method in phase 1 and 89% in phase 2.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit