Strengthening the Foundation for Health-Related Needs Screening to Better Support Patients

Every health center leader knows why screening for health-related needs is important. Food, housing, transportation, and social connections shape health outcomes far beyond what happens in an exam room. A harder question is: what does a health center need to have in place before screening can truly improve a patient's life? 

Across FUHN's member health centers, the data are starting to show the answer. The share of patients screened for health-related needs more than doubled between 2023 and 2025. Behind that progress are lessons from leaders like Chris Singer, DNP, RN, CPHQ, Clinical Director at Native American Community Clinic (NACC), who has approached the question from two very different vantage points.

What the evidence shows

Before joining NACC, Chris spent roughly a decade at Minnesota Community Care (MCC), where she led a care coordination project that became the basis for her doctoral work and a 2022 peer-reviewed study. Most health systems decide who gets intensive care coordination using claims-based risk scores, which capture diagnoses and utilization but miss what patients face at home. Chris's project added PRAPARE, a standardized health-related needs screener developed for community health centers, to that process. Medical assistants, matched to patients by language, race, and ethnicity, served as care coordinators who checked in monthly. At each check-in, coordinators used NowPow, a community referral platform connected to the electronic medical record (since acquired by Unite Us), to identify resources and send real-time referrals to community organizations, with information flowing back to the clinic.

Among the 216 patients who opted in, the share reporting trouble getting food fell by about half, housing worries dropped significantly, and patients' anxiety eased. For Chris, the impact went beyond the numbers. As their barriers decreased, the patients reported less stress and more joy. Connecting monthly with a care team member also built something harder to measure: a relationship with a trusted person who could align resources around what each patient needed.

"While the screening doesn’t give us all of the answers," Chris said, "it does help us dig a little bit deeper than just looking at an A1C."

Why it worked at MCC

Chris is quick to credit the conditions for the success. MCC's leadership committed real resources, a quality program already existed, and a formal team-based care model meant medical assistants had established relationships with providers. Plus, screening data fed directly into clinical dashboards, so staff could see, for example, how transportation barriers affected which women were overdue for cervical cancer screening. Screening became part of the regular workflow because it could be attached to the medical records.

Building the foundation at NACC

When Chris started at NACC about four years ago, she was immediately impressed by the cultural practices infused into clinical care. She remarked that she had never seen that integration done so well. NACC’s clinical operations infrastructure was early in development, so Chris knew regular health-related needs screening would take some time. 

"It’s challenging to step in and just implement a new workflow or system,” said Chris. “You have to have foundational systems to build on."

That's what she's been doing. Today, NACC has improved screening rates by about 20 percent, and the clinic hired its first dedicated quality manager this year. "You cannot force a system to move faster, and we’re excited to see momentum and progress.” 

The next step is strengthening what happens after a patient screens positive for health-related needs. As a smaller organization, NACC doesn’t always have staff available to provide a “warm handoff” to a partner agency when a patient wants help with resources. The team is now reviewing data on how often those connections happen. As a team, Chris and her colleagues are being thoughtful about the system they’re designing, making sure that community members and partners are at the table. They’re continually listening to the community and adjusting, knowing the work is never finished.

Measuring what matters

A dedicated FUHN board workgroup staffed by Mark Sonneborn, FUHN's Data Analytics Consultant, meets every other month to consider how best to screen for health-related needs across member clinics and the network. Building on that work, a small group of Quality Committee members is also collaborating to learn from other clinics, examine best practices, and make recommendations to the broader Quality Committee and the Health-related Needs Workgroup. 

FUHN’s approach with the two groups mirrors Chris’s: start with what's manageable and build from there. Member health centers began with PRAPARE, the same comprehensive tool Chris used at MCC. To make screening routine across different clinics that vary by size, location, patient populations, and more, the Health-related Needs Workgroup focused on three things: sharing best practices among members, adopting minimum standards for how often patients are screened, and streamlining screening to four core areas—housing, food, transportation, and finances—that most directly affect patients' health and ability to access care.

The results followed. The share of patients screened for health-related needs across FUHN clinics increased from 14 percent in 2023 to 29 percent in 2024, and to more than 33 percent in 2025. The workgroup emphasized data and tracking because you don’t improve what you don’t measure, a principle that depends on infrastructure.  

Screening results, however, drive improvement only when documented consistently in the EMR, where staff can see them alongside clinical information and act on them. Across a network, standardized data collection means health centers can compare progress, spot gaps, and learn from each other. Plus, it gives FUHN leaders a clearer picture of where each member is in its development so support can go where it's needed most.

Closing the loop

Screening is only the first step. The real measure is whether a patient who screens positive gets connected to help—and whether that connection makes a difference. That's where the EMR becomes essential. When screening results, referrals, and follow-ups all live in the EMR, care teams can see whether a referral was made, whether the patient received help, and how their health changed over time. Bidirectional referral systems—like the one Chris's team used at MCC—send information back to the clinic so patients don't fall through the cracks. NACC wants to uncover the same: not just how many patients were screened, but how many were helped.

That answer matters for patients—and for health centers’ sustainability. Under value-based care, health centers are rewarded for keeping patients healthy rather than for the volume of services they provide. Health-related needs often stand between a patient and better outcomes, whether it's a missed appointment because of transportation or uncontrolled diabetes due to food insecurity. Chris's research points to the gap: traditional claims-based risk tools miss these needs entirely, and even as value-based payment models fund more care coordination, resources often fall short of the depth of support patients need.

Part of the answer is coding. Z codes, the diagnosis codes that document needs like housing instability and food insecurity, turn screening results into data that payers and risk models can see. When health centers use them consistently, health-related needs that claims-based tools have long missed start showing up where funding decisions are made, strengthening the case for investing in the care coordination that addresses them.

Chris's experience at NACC reminds us that the numbers tell only part of the story. Behind every screening rate is a health center building systems to ask the right questions about health-related needs—and a care team working to make sure patients can access the necessary support and resources.