Table 2.

Interview Topics, Themes, Subthemes and Representative Quotes.

Topic	Themes	Sub-themes and representative quotes
Social Determinants of Health	Screening	“They just started at the hospital but not in our clinic, not sure the tool used.” “So, my clinic itself does not have like a, “Yes, this is what we’re going to do.” I, myself, yes, I have an initial face sheet that I go over with the patient to see where they’re at, access to medications, what their insurance is, what their living situation is.” “We don’t have a lot of capacity to do that here. We do have our triage nurses that help a lot with the community and getting that information out to patients, but we just don’t have any social workers, anything like that, that can really take that next step.”
	Patient needs	Access to Transportation “Transportation is huge in Kansas.” “We have many patients who struggle to get to their appointments with us because they don’t have transportation.” “We have company vehicles that our staff use, you know, to help with transportation, but it’s just not enough for what the need is truly. I would say that transportation is our biggest barrier.” “I think one of the hardest ones is transportation. Out here it’s not like you just call an Uber.”
		Finances “So, some of what we see right now is that we have a large number of people who are having a harder time with their day-to-day expenses, things like groceries and gas are a real challenge. People are making big changes in how they choose to spend their money, what money they make.” “Medication costs continue to go up, as does cost of food and everything else. So if you’re gonna pick one or the other, you’re probably not gonna take meds.”
	Resources	Availability of Resources “There is not much here at the facility, I’m trying to think of what even, I can’t think of what we have now in the community.”
		Community and Clinic Resources “Nothing organized . . . maybe Meals on Wheels. We do depend on the Council on Aging for some services for our older populations. We have a food pantry. But, in general, I would say it’s pretty limited.”
		Clinics’ Knowledge of Resources “Sometimes it’s much more affordable for them if they get their care through one of the FQHCs in town, so sometimes we are answering their need by telling them to go somewhere else.”
Community Health Workers (CHW)	Utilization	Desire for CHW Utilization “A CHW would be able to do a lot of the things that I want to do for my patients, but I just simply don’t have time, kind of that, like, wraparound care. Instead of me feeling like I’m going up against a brick wall to be able to get my patient what she needs, give those very, like, tangible sort of services like taking a form to someone’s house to help them get food.”
		Barriers to Utilization “We have no idea where to find people. I mean, there is just, there’s just nobody. It’s our biggest challenge right now” “We have currently somewhere upwards of 12 to 15 open positions in our small rural facility so any employee alone would be wonderful. The community health worker seems like a dream right now.” “Number one is cost, and then number two is availability of somebody that would be able to do a service like that here.”
		Impact for Clinics with Current CHW Utilization “Oh my gosh, we rely on them so much . . . to have someone there to help listen and understand what their needs are . . . I mean, they help us with so many things. Our patients have built relationships with them as well. I just, I just can’t say enough about them. We utilize them all day long.” “Our CHW can just drop what they’re doing and meet the patient where they’re at because if they’re willing to bring [their social needs] up, but then we say, ‘Oh, we’ll get back to you in a couple of weeks’. Well, by that part, you know, who knows if we’ll get in touch with them again. We miss that opportunity to help sometimes.”
	Impact	Potential Benefits of CHW Utilization “They would be able to make patients more aware of resources, make us more aware of resources, take some of the stress off of our care managers. They do everything they can, but it gets to be a lot. So, anyone who is aware of resources and programs that we might not know of or just even have the ability to set our patients up with those would be very helpful.”