Centering the Role of Community Health Workers in Social Risk Screening Within the Primary Care Setting

Abstract

CHWs remain an underutilized resource in social risk diagnostics in the primary care setting, despite their demonstrated effectiveness in community programs for disease prevention. This implementation study seeks to document the role of CHWs in addressing social risk in primary care by process mapping social risk screening procedures. Researchers at The University of Arizona engaged with two FQHCs in two of Arizona’s major urban areas to better understand their processes for social risk screening in the clinical setting. The CFIR framework was used to direct a process mapping exercise to visually describe the workflow, gaps, and opportunities for SDOH screening. Partnering FQHCs generated professionally diverse and collaborative teams to unveil key areas for health system improvements within their own organizations. These included clear channels for clinician referral to CHWs, resolution of IT challenges, and a more universal system for CHWs to refer to community partners. This study demonstrates the importance of CHW integration in primary care teams to fully identify and respond to the SDOH needs of patients. Subsequent research will evaluate rates of social risk screening within all of Arizona’s FQHCs and propose models for CHW integration in primary care to strengthen social risk screening reach and effectiveness.