Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers

Abstract

Objectives

Despite an increasing emphasis from health care organizations on patients’ social health, there is debate about how best to screen patients for social health needs in practice. Empathic Inquiry is a patient-centered approach to asking about patients’ social needs that incorporates motivational interviewing and trauma-informed care techniques to increase patient experience of trustworthiness and safety with their care teams. The purpose of this brief report is to describe the feasibility and acceptability of implementing an Empathic Inquiry–informed approach to social needs screening in 10 federally qualified health centers.

Methods

Clinical staff at community health centers implemented Empathic Inquiry as part of an 8-month learning collaborative. Patients completed surveys about their experience with Empathic Inquiry after screening conversations took place. Qualitative data on organizational implementation experience were collected monthly during 2018.

Findings

Eight of 10 organizations completed the learning collaborative and implemented Empathic Inquiry in practice. Of 132 patient surveys received, patients agreed (64% strongly agree, 28% somewhat agree) that being screened for social needs strengthened their relationship with their care team and 83% strongly agreed the conversation was a good use of time. Most patients (54%) indicated social health screening was appropriate at every visit, and 27% answered once every 6 months.

Conclusions

The Empathic Inquiry approach to understanding patients’ social needs was feasible for implementation in community settings. Patients said the conversations were worthwhile, built trust with their care teams, and should be conducted every 6 months or more frequently.

Introduction

Over the last decade, there has been a rising tide of interest in addressing health-related social needs, such as lack of affordable housing, inadequate access to transportation, and food insecurity, which are the “downstream consequences of social determinants of health for people who have been systematically disadvantaged.” ¹ Requirements for responding to social needs are now integrated into the National Committee for Quality Assurance Patient-Centered Medical Home standards, and some Medicare and Medicaid payment models have already begun to incentivize screening. Additionally, social needs screening will be measured by a new Healthcare Effectiveness Data Information System quality metric beginning in 2023. ^2–5

There is, however, a sustained debate about the best methods, setting, and purpose for conducting social needs screening. A recent report concluded that more rigorous research is needed on all aspects of social needs screening in health care, noting significant variation in setting and modality, workflow design and workforce deployment, as well as population participation in screening completion. Although screening strategies vary across settings and populations, there are no discernable patterns identifying which screening formats are most successful for diverse population segments. ⁶

Most implementation efforts frame screening as a means to an end. End goals range from shaping patient-level interventions, such as adaptation of clinical care plans and referral to community-based resources, to influencing population-level objectives, such as establishing associations between the presence of social needs and health status, and development of risk adjustment for predictive utilization and cost modeling. ^7,8 Recent findings suggest that more attention should be paid to how the process of screening itself impacts the people involved, including the implications for trusting patient and care team relationships and patient participation in social health programming.

Most people generally regard social needs screening in health care as acceptable, and studies find a positive correlation between trust and acceptability. Patients with higher trust in their practitioner(s) find social screening more acceptable, and people with prior experiences of discrimination in health care settings find screening less acceptable. ⁶ Similarly, people already experiencing social marginalization or less connection to their primary care team may be less receptive to social needs interventions. ^9,10

Patient-centered communication practices can reduce stigma and may increase the success of screening and referral. Creating trustworthy and respectful social needs screening interactions is critical to facilitating successful engagement for diverse populations, including those who have experienced prior discrimination or have a lower level of trust in health care practitioners and institutions. ^6,9–13

Empathic Inquiry is an approach to screening for social needs that was created using evidence-informed best practices along with patient and professional stakeholder input, and is intended to facilitate collaboration and psychological safety during social needs screening and follow-up conversations. The Empathic Inquiry model incorporates strategies from motivational interviewing and trauma-informed care, as well as input from stakeholders, including patients, community health workers and their supervisors, community health center clinical and operational leaders, and experts in trauma-informed care. Empathic Inquiry was created by the Oregon Primary Care Association (OPCA), the association representing the state’s federally qualified health centers (FQHC). More information about the specific guidance offered by Empathic Inquiry can be found on the OPCA website. ¹⁴

The purpose of this brief report is to describe the impact on clinic-level implementation and patient experience of a focused Empathic Inquiry intervention in 10 FQHCs. This study provides novel insights into the feasibility and usefulness of a robust social needs screening approach as an important component of building trust among patient and care teams around social health.

Methods

Empathic inquiry was introduced through an 8-month learning collaborative to 28 clinical staff from 10 community health centers in Oregon in 2018 (participating FQHCs and staff are described in Table 1). The learning collaborative included an initial 2-day, in-person interactive training led by the program creators, monthly skill-building and implementation support webinars that emphasized peer-to-peer sharing of best practices and lessons learned, and a closing 1-day reflection and reinforcement workshop. Clinic staff used the skills acquired in these trainings to improve social needs screening conversations at their FQHC sites. Workflows for when and where these conversations took place varied by FQHC and over time as sites experimented with ways to improve screening.

Table 1:

Federally qualified health centers' organizational characteristics

Organizational and Participant Characteristics	Mean or percent (population standard deviation)
Average number of patients served by each organization	11,387 (7,817)
Average no. of clinic sites operated by each FQHC organization	7
Clinic location
Rural	40%
Urban	30%
Urban and rural	30%
Staff FTE	131.25 (98.72)
Titles of Empathic Inquiry workshop participants
Patient or program coordinator/navigator/resource specialist	32%
Community health worker	25%
Medical assistant	21%
Director/supervisor	14%
Registered nurse	7%
Participating in alternative payment methodology
Yes	80%
No	20%

Patient experience surveys were administered after the completion of Empathic Inquiry screening conversations with trained FQHC staff, but before being linked to services. Patients were given a paper copy of the survey by FQHC staff, along with an envelope to seal the survey for confidentiality. Completed surveys were collected by FQHC staff and submitted to the evaluation team. Patients who completed the survey were offered entry into an incentive lottery for a $50 gift card to a retailer of their choice using an online platform.

Patient experience surveys were based on the consultation and relational empathy (CARE) measure, and also included questions relating to appropriateness and frequency of social needs screening. The CARE measure was developed at the University of Glasgow and has been validated and extensively used in Scotland to measure a holistic, patient-centered, and empathic approach to care. ¹⁵ Descriptive analyses were conducted to measure the count and prevalence of patient survey demographics (Table 2) and survey responses (Table 3).

Table 2:

Demographic characteristics for patients who completed survey

Characteristic (N = 132)	%
Age
18–30	14
31–50	43
51–64	26
65+	12
Gender
Women	60
Men	35
Nonbinary/Third Gender	2
Education
Some high school or less	16
High school diploma or GED	30
Vocational, technical, trade school	11
Some college	30
College graduate or advanced degree	8
Household income
Less than $5000	35
$5001–$14,999	20
$15,000–$24,999	22
$25,000–$34,999	6
$35,000–$49,999	7
$50,000–$74,999	2
$75,000 or more	2
Race/ethnicity
American Indian/Alaska Native	2
Black	2
Latino/Hispanic/Spanish	15
Native Hawaiian/Pacific Islander	1
White	64
Multiracial/ other	10

Note: Numbers may not sum to 100 because of rounding.

Table 3:

Empathic Inquiry patient survey results

Characteristic (N = 132)	% a
How good was the person you spoke with today at making you feel at ease?
Excellent	80
Very good	14
Good/fair/poor	7
How good was the person you spoke with today at letting you tell your story?
Excellent	77
Very good	17
Good/fair/poor	6
How good was the person you spoke with today at really listening?
Excellent	80
Very good	14
Good/fair/poor	6
How good was the person you spoke with today at being interested in you as a whole person?
Excellent	77
Very good	18
Good/fair/poor	5
How good was the person you spoke with today at fully understanding your concerns?
Excellent	79
Very good	14
Good/fair/poor/NA	7
How good was the person you spoke with today at showing care and compassion?
Excellent	77
Very good	14
Good/Fair/Poor	8
How good was the person you spoke with today at being positive?
Excellent	81
Very good	11
Good/fair/poor	8
How good was the person you spoke with today at explaining things clearly?
Excellent	85
Very good	8
Good/fair/poor	8
How good was the person you spoke with today at helping you to take control?
Excellent	77
Very good	12
Good/fair/poor	7
How good was the person you spoke with today at making a plan of action with you?
Excellent	77
Very good	12
Good/fair/poor	8
After my conversation today, I have a better relationship with my care team.
Strongly agree	64
Somewhat agree	28
Disagree	2
After my conversation today, I know more about how the health center can assist me with needs beyond my medical care.
Strongly agree	74
Somewhat agree	20
Disagree	2
After my conversation today, I have the information I need to reach out to these new resources.
Strongly agree	75
Somewhat agree	20
Disagree	2
After my conversation today, I feel confident I can get the help I need.
Strongly agree	80
Somewhat agree	16
Disagree	4
After my conversation today, I felt the conversation was a good use of my time.
Strongly agree	83
Somewhat agree	14
Disagree	2

Note: Total surveys received = 132 (English = 116, Spanish = 16).

^aNumbers may not sum to 100% because of response of “don’t know” or “not applicable.”

Organizational reports were collected monthly for 6 months via a SurveyMonkey link distributed to each learning collaborative participant, and included questions about organizational workflows, confidence, implementation challenges, and successes. Author AS reviewed the reports and derived themes inductively on implementation barriers and successes. Prevalence of themes across reports were reviewed by AS and KC and summarized here.

This project was reviewed by the Kaiser Permanente Washington Human Subjects Review Office; as a quality improvement program, it was determined to not require IRB review.

Findings

Patient experience

Most patients felt that it was appropriate to be asked about their social and economic needs (80% completely agree, 10% somewhat agree), and nearly all believed it should occur every 6 months or more frequently (54% every time I receive care, 27% once every 6 months). Patients noted that the Empathic Inquiry conversation strengthened their relationship with their care team (64% strongly agree and 28% somewhat agree), and 98% agreed (83% strongly agree and 14% somewhat agree) that the conversation was a good use of their time, even though in most cases the patient did not have an existing relationship with the staff member (56% had never met them before and 30% had interacted with the person once or twice before).

More than three quarters of 132 patients who responded to the patient survey said that the staff member who conducted the Empathic Inquiry conversation was “excellent” at making them feel at ease, really listening, fully understanding their concerns, and explaining things clearly.

Clinical implementation

Significant clinic resources are required to scale up screening patients for social needs, and a common set of implementation challenges emerged from the organizational reports. These challenges are consistent with those published elsewhere and included the importance of dedicated staff and physical space for conducting nonclinical conversations, adequate time in the patient visit flow, and cooperation from other members of the care team to implement social needs screening and connect with patients for a meaningful follow-up conversation. ^16,17

In addition to the resource challenges, staff members also noted that an open-ended, empathic approach to social needs conversations was at odds with other organizational priorities for their work, such as visit flow and screening efficiency and completion. Many recommended greater leadership support for implementation of an empathic style of conversation across the organization so that patients are offered a consistent experience of trauma-informed care.

Discussion

The findings suggest that Empathic Inquiry is a feasible and acceptable approach to discussing social needs with patients. Among the patients who completed the post–Empathic Inquiry satisfaction survey, most felt that the Empathic Inquiry conversation improved their relationship with their team and was a good use of their time, despite mostly having no prior relationship with the team member facilitating the screening conversation. This finding suggests that Empathic Inquiry may be particularly well-suited for engaging patients who do not feel connected to their primary care team and may be less likely to disclose social risks. ¹⁰ It is notable that this survey was administered following the screening conversation, but before any referrals to resources were made. Many professionals and organizations hesitate to screen for risks that they cannot address; ⁶ our findings suggest that an empathic conversation about social health constitutes a meaningful and acceptable follow-up to a positive screen. Regardless of resource availability or navigation, health care organizations can facilitate interactions that are focused on developing partnership with patients and support for patient-defined goals, rather than relating to patients and their circumstances as problems to be solved. As 1 community health worker supervisor from a participating community health center stated, “We cannot always solve their problems, but we can always leave them feeling seen, feeling heard, and feeling respected.”

Although organizations participating in the pilot faced implementation challenges consistent with those experienced elsewhere, much more needs to be learned about the facilitators of social health implementation success. In the Empathic Inquiry pilot, 2 critical factors seemed to make a difference in FQHC implementation: reimbursement methodology and leadership engagement. Eight of the 10 FQHCs who initially signed up to participate in the Empathic Inquiry learning collaborative were participants in an alternative payment methodology (APM) that converts their fee-for-service payment into a capitated payment model. This payment reform enables FQHCs to expand care teams and visit times, both of which are critical for effectively understanding and responding to social needs at the team level. Of the 2 non-APM FQHCs participating in the learning collaborative, one dropped out and the other achieved only limited implementation during the Empathic Inquiry pilot.

The FQHC with the most extensive screening implementation, demonstrated by the high number of patient satisfaction surveys completed, benefited from the presence of a highly engaged operational leader, who maintained substantial participation in the pilot by attending the Empathic Inquiry trainings and using reliable quality improvement methods to facilitate implementation and improvement across the FQHC team. ¹⁸ This strategy for success aligns with the first 2 of Bodenheimer’s 10 building blocks of high-performing primary care and suggests that the same strategies that have enabled other primary care efforts to enhance whole-person care are relevant to integration of social health. ¹⁹ This finding is consistent with the Social Interventions Research and Evaluation Network State of the Science report finding that both training and continuous quality improvement increase adoption. ⁶

The limitations of these findings include limited survey reach and unknown response rate. Out of 10 community health centers, 8 completed the learning collaborative and implemented Empathic Inquiry in practice, and 132 patient surveys were completed. Most patients who completed these surveys identified as white women between the ages of 31 and 64, who earned less than $24,999 per year. Significant limitations to the survey data include: data was collected only at clinics that agreed to participate in the pilot, and from patients who agreed both to complete social health screening and the patient experience survey. The total number of patient experience surveys distributed is unknown; it is difficult to discern whether only patients who had a positive experience completed the survey.

Conclusion

As system-level forces, including accreditation agencies, quality metrics, and payment incentives, push organizations toward broader adoption of social needs screening, empathic screening conversations may serve as a starting point for engaging patients in a meaningful conversation about social needs and health, thereby enabling teams to offer contextualized care and link patients to resources when available. ²⁰ In addition to promoting engagement in health care shaped by patients’ social circumstances, empathic, whole-person conversations may also lead to increased relational quality and trust with clinical staff.

Empathic Inquiry demonstrates promise as a patient-centered approach to social needs screening that is built on patient-centered communication best practices and is well accepted by patients. After the implementation of the Empathic Inquiry pilot, additional data suggest that this approach is consistent with patient preferences and essential for using social health screening to improve health equity. ^9,10,12 More rigorous empirical research is needed.