Introduction  

Federally Qualified Health Centers (FQHCs) play a crucial role in the American healthcare system, serving as a lifeline for underserved and vulnerable populations. With over 30 million Americans relying on FQHCs for primary care annually (HRSA, 2023), these centers are at the forefront of community health. Yet, their ability to deliver impactful care is increasingly challenged by the social determinants of health (SDOH)—non-medical factors that significantly influence health outcomes. 

More than 1 in 10 patients at FQHCs face major SDOH-related barriers such as housing instability, food insecurity, lack of transportation, and financial strain (JAMA Internal Medicine, 2022). These risk factors are not just background noise—they are the root causes of poor adherence, chronic disease progression, missed appointments, and increased hospitalizations. 

This blog expands on our earlier FQHC guide and offers a deeper dive into how SDOH impacts care delivery—and how FQHCs can adopt a structured, data-informed approach to care management that bridges clinical and social care.

What Are Social Determinants of Health (SDOH)?  

According to the World Health Organization, SDOH are the conditions in which people are born, grow, live, work, and age. The CDC classifies SDOH into five key domains: 

1) Economic Stability – Employment, income, expenses, debt, medical bills 

2) Education Access and Quality – Literacy, language, early childhood education 

3) Healthcare Access and Quality – Health coverage, access to care, provider bias 

4) Neighborhood and Built Environment – Housing, transportation, safety, walkability 

5) Social and Community Context – Social integration, support systems, discrimination 

When these domains are compromised, even the best clinical interventions can fall short.  

Bridging the Gap Between Clinical and Social Care 

FQHCs are uniquely positioned to close the gap between clinical needs and social realities. But doing so effectively requires more than goodwill—it demands infrastructure, intention, and innovation. To bridge this gap, FQHCs must: 

• Acknowledge SDOH as Clinical Risk Factors: Treat social needs as core components of the care plan—not as external issues. 

• Empower the Care Team: Equip staff with tools and training to identify and respond to non-clinical barriers. 

• Embed SDOH Data into Workflows: Integrate screening and documentation directly into EHR systems and daily care routines. 

By shifting from reactive care to proactive, personalized interventions that consider social context, FQHCs can dramatically improve long-term outcomes for their patients. 

Why FQHCs Need to Address SDOH Proactively 

FQHCs serve communities where SDOH-related challenges are the norm, not the exception. Left unaddressed, these barriers drive up healthcare costs, reduce provider productivity, and worsen patient outcomes. 

Addressing SDOH is not an add-on; it’s central to mission-driven, value-based care. Incorporating SDOH data into care planning allows providers to: 

• Tailor interventions to each patient’s reality 

• Improve medication and care plan adherence 

• Prevent avoidable ED visits and readmissions 

• Increase patient satisfaction and trust 

Solutions: What FQHCs Can Do Today 

1. Screen for SDOH Systematically 

• Use standardized tools like PRAPARE, AHC-HRSN, or the CMS SDOH ICD-10 Z codes 

• Embed SDOH screening into intake workflows 

• Train staff to ask sensitive questions with empathy and cultural competence 

2.  Build Partnerships with Community-Based Organizations (CBOs) 

• Refer patients to housing services, food pantries, transit assistance 

• Establish closed-loop referral systems that track follow-ups 

• Apply for HRSA or CDC grants to fund local partnerships  

3. Implement a Tech-Enabled Care Management Model

• Use EHR-integrated platforms to track SDOH and risk stratify patients 

• Deploy multilingual RNs for patient outreach and education 

• Utilize care coordination dashboards for follow-ups, flags, and escalations 

• Partner with specialized care management companies that offer end-to-end support—from SDOH screenings and resource referrals to continuous patient follow-up—so your team can focus on clinical excellence while extending their reach into the community 

4. Leverage Value-Based Payment Models 

• Many state Medicaid programs offer SDOH-related incentives under Managed Care Organizations (MCOs) 

• Participate in CMS programs like ACO REACH, CHART Model, or Community Health Access and Rural Transformation 

 5. Monitor and Share Data Outcomes 

• Report improvements in hospitalization rates, patient-reported outcomes, and cost savings 

• Use data insights to apply for funding and scale successful programs 

  
  

How Sciometrix Helps FQHCs Address SDOH? 

At Sciometrix, we understand that SDOH data isn’t just information—it’s a call to action. We deliver care management services like Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). Our platform is built to bridge the clinical-social care divide: 

• Risk Stratification Built into Workflows – Our system flags patients with high social risk automatically 

• US-Based RN Outreach – Our nurses assess and follow up on SDOH in real-time Community

• Resource Integration – Our platform connects with CBOs to close the loop Multilingual,

• Culturally Sensitive Support – Because equity starts with access 

• Data Reporting for Grant and Compliance Needs – Supporting your funding and policy efforts 

  
  

Conclusion: Leading the Future of Community Health  

Addressing SDOH isn’t a luxury—it’s a necessity for FQHCs to thrive in a value-based world. Through structured programs, data-driven tools, and community partnerships, FQHCs can overcome systemic barriers and provide transformative care. 

At Sciometrix, we are proud to be a trusted partner in this journey. Together, we can move the needle on care delivery—one patient, one intervention, one community at a time.