Programs to screen for social and economic needs (SENs) are challenging to implement.


To describe implementation of an SEN screening program for patients obtaining care at a federally qualified health center (FQHC).


Large Chicago-area FQHC where many patients are Hispanic/Latino and insured through Medicaid.

Program Description

In the program’s phase 1 (beginning April 2020), a prescreening question asked about patients’ interest in receiving community resources; staff then called interested patients. After several refinements (e.g., increased staffing, tailored reductions in screening frequency) to address challenges such as a large screening backlog, program phase 2 began in February 2021. In phase 2, a second prescreening question asked about patients’ preferred modality to learn about community resources (text/email versus phone calls).

Program Evaluation

During phase 1, 8925 of 29,861 patients (30%) expressed interest in community resources. Only 40% of interested patients were successfully contacted and screened. In phase 2, 5781 of 21,737 patients (27%) expressed interest in resources; 84% of interested patients were successfully contacted by either text/email (43%) or phone (41%).


Under one-third of patients obtaining care at an FQHC expressed interest in community resources for SENs. After program refinements, rates of follow-up with interested patients substantially increased.

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Health Equity, JGIM, Social Determinants of Health, Vulnerable Populations

Author Descriptions

Erie Family Health Centers, Chicago, IL, USA

Lacey Johnson MPH, Paula Carcamo BA, Bridget G. Magner MPH & Josephine Llaneza MPH

AllianceChicago, Chicago, IL, USA

David T. Liss PhD & Ta-Yun Yang MS

Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

David T. Liss PhD & Mita Sanghavi Goel MD, MPH, FACP