The Institute for Family Health (IFH) is a federally qualified health center (FQHC) providing primary health care to vulnerable medically underserved populations in the Bronx, Manhattan, and in the Mid-Hudson Valley. IFH operates 20 full-time and 7 part-time practices that, together, serve over 98,500 patients, providing them with medical, dental, and behavioral health care.
Recently, over an 18-month period, the Altman Foundation supported a pilot project to test the feasibility of screening all patients for social determinants of health in a safety-net primary care setting, implementing a referral protocol, and integrating tracking and reporting functionality into its electronic health record system. The screening tool tested by IFH contained five simple questions, probing issues and challenges related to housing stability, food security, economic security related to health care and medications, experience with violence or abuse, and community safety. At its Urban Horizons Family Health Center in the South Bronx, IFH screened 3,053 patients (99% of those eligible). Of those screened, 17% responded positively to one of 5 questions on the screening tool and 35% responded positively to more than one question; 77% of all patients who screened positive were then referred to an on-site social worker or case manager. The results of the project were presented at the recent "Population Health Summit IV: Working Across Sectors to Address Social Determinants of Health" (December 12, 2016) at the New York Academy of Medicine. In short, the pilot established that systematic screening and referral for social determinants of health was both feasible and acceptable to patients and staff. IFH is now engaged in an effort to collect qualitative feedback and to rigorously assess its ability to address the social determinants that patients identify.