The American Journal of Accountable Care®
June 2024
Volume 12
Issue 2

Barriers and Facilitators to Managing Social Care in the Digital Era Among Michigan Health Centers

There is widespread interest in understanding the role of health care in meeting social needs. This study examines community-wide activities, resources, and information technology used to manage social care.


Objectives: Health care organizations are taking a greater role in providing social care. Federally qualified health centers (FQHCs) lead these efforts, leveraging investments in technology to manage patient care and information. This study describes the challenges of meeting patient social needs and presents new opportunities for engaging in community-wide activities to address care and quality.

Study Design: Sociotechnical systems theory was applied in
qualitative research.

Methods: Eleven of the 40 Michigan FQHCs were recruited into the study. Twenty-five semistructured interviews were conducted with practice leadership, clinicians, and staff to explore information technology and other resources used for managing social care. Analyses of the interviews were used to organize infrastructural and technological factors that emerged into key themes.

Results: Interviews revealed that Michigan FQHCs participated in community-wide activities to develop value-based care practices and quality initiatives using shared data and technology. Study participants revealed that their community-level involvement facilitated improved data management, digital information sharing, and quality improvement efforts. Ultimately, however, limited housing services and inadequate behavioral health care created challenges in connecting patients with essential treatments and social supports.

Conclusions: Developing information infrastructure and new technological capabilities to manage patient care and population health is necessary but insufficient. Major investments in both technology and human capital are critical to effectively provide social care and improve quality. Building on the evidence gained from FQHC partnerships and data activities offers public officials and health care leaders insight into the local resources and policy changes that are needed.

The American Journal of Accountable Care. 2024;12(2):9-15.


Health departments and social services have long recognized social risks (eg, food insecurity, housing instability, unemployment), providing necessary interventions to individuals and communities. Within the health care system, screening for social risks and responding to patients’ social needs (eg, food, housing, and employment) are growing priorities.1 Information technology (IT) is increasingly being used to document social needs2 and coordinate services often outside of traditional medical care. The changes occurring in practice are in part prompted by new payments and quality measures used to improve patient care and population health.3 This shift to provide social care (eg, food assistance, housing services, job support) has helped to redefine the roles of public health and social services as critical agents in health care delivery.

Despite the evolving landscape, there are challenges to integrating social care into medical practice4 and managing care delivered in communities. A better understanding of the infrastructural and technological factors is necessary to effectively guide policy and practice changes. Efforts to study health care partnerships and activities at the community level are more apparent among government programs and demonstration projects. Federal agencies and researchers are examining new payment and care models used to meet health-related social needs.5

Investigations of population health initiatives led by public and private payers are also demonstrating the efficacy of using IT to screen for social risks, refer patients to community services, and identify health plan superutilizers by accounting for different social factors.6,7 However, studies systematically examining the local infrastructure and data activities that have emerged are needed. To our knowledge, this is the first study of its kind to investigate health care partnerships and community resources used to provide social care among a statewide network of federally qualified health centers (FQHCs).

Nationally, FQHCs represent cornerstones of public safety net systems in more than 12,000 communities.8 They are influential in shaping local policies to improve access to quality medical care. Historically, FQHCs have met complex patient needs through partnerships with health departments and social services.9 In recent years, FQHCs have leveraged their IT investments to adopt social care data collection standards supported by their national network of 1370 health centers.10 Increasingly, FQHCs are using electronic health record–embedded screening tools and data analytic software to identify social risks and manage care needs.11 The role and involvement of FQHCs in actively developing local information infrastructure and sustainable social care models offer insight and provide a setting in which to examine the barriers and facilitators to delivering high-quality care in the digital era.

In this study, an academic-community research partnership guided the investigation of local resources, workforce, and IT adopted by Michigan FQHCs and partner organizations. The purposes of the study were to (1) offer policy makers a better understanding of the investments in local infrastructure needed and (2) present health care leaders with opportunities to support social care integration and respond to local health needs. The study describes the advantage of participating in community-wide activities and identifies which social care needs are most difficult to meet. Investigators drew on sociotechnical theory to reveal the human/organizational and technological elements of the local information infrastructure and care management activities developed in Michigan communities.12,13 A sociotechnical systems model was used to categorize community priorities, IT adopted, and workforce developed to manage social care and address quality.14 Results were presented to answer these research questions: (1) What are the facilitators of participating in community-wide activities to deliver high-quality care? and (2) What are the barriers to meeting patient social care needs in communities?


This is a qualitative study of community-wide activities and resources used to deliver social care. Investigators defined social care as screening for risks, diagnosing care needs, and providing at least 1 of the following services: food assistance, housing, transportation, financial assistance, legal assistance, employment, or educational support. Screening, diagnostics, treatment, and referrals for child maltreatment, intimate partner violence, substance use disorder, and mental health needs were categorized by investigators as care activities used to address patient safety and well-being.

Setting and Site Selection

Sampling was used to recruit FQHCs and participants through the academic-community partnership with the Michigan Primary Care Association and its network of primary care practices in Michigan. The investigation was limited to FQHCs in Michigan (N = 40). The study was determined to be exempt from review by the University of Michigan Institutional Review Boards. All Michigan FQHCs were eligible to participate in the study. FQHCs were recruited through an online webinar in June 2021. Webinar attendees consisted of quality directors and chief operating officers from all 40 Michigan FQHCs. Purposive sampling was used to correctly identify the appropriate FQHC employees within each practice to enroll in the study. Gift cards ($25 each) were provided to study participants for their interview participation. Informed consent was received from each participant interviewed.

Semistructured Interviews

A semistructured interview guide was created to explore the infrastructural and technological factors related to meeting patient care and community health needs among Michigan FQHCs and their partners. Sittig and Singh’s sociotechnical systems model for studying IT adoption and use in adaptive health care settings informed the questions asked.14 All 8 dimensions of the model—hardware and software; clinical content; people, workflow, and communication; human-computer interface; organizational policies and procedures; culture; external rules, regulations, and pressures; and system measurement and monitoring—were used to conceptualize the characteristics of community-wide activities, partnerships, resources, and IT adopted.15 The 22-question interview guide (eAppendix [available at]) was developed, iterated, and tested through the academic-community research partnership. Interviews were conducted and recorded using video conferencing. Study participants were asked about the challenges of meeting social needs in the community and partnerships formed to improve care coordination and develop IT infrastructure.

Data Analysis

A qualitative rapid assessment process (RAP) was used to develop a data extraction template tool based on the sociotechnical model described. RAP is an intensive, team-based qualitative inquiryusing data triangulation, iterative analysis, and additional data collection to quickly develop an understanding of a situation, setting, or phenomenon from an insider’s perspective.16 RAP is a demonstrated and efficient method for time-sensitive health services research used in evaluations of applied clinical informatics across settings (eg, hospitals, primary care).17 The data extraction template tool was tested by the investigators for consistency and reliability before transcript coding commenced. The coding occurred until data saturation was achieved and disconfirming data were no longer identified. Data matrices were derived from the extraction template tool and used to capture coded information regarding sociotechnical domains from the transcripts. Domain and subdomain summary profiles were then created to analyze the multilevel factors, barriers, and facilitators associated with setting and community differences. A thematic analysis was completed to identify factors and themes related to building local capacity and meeting patient care needs.


Practice leadership, clinicians, and staff (n = 25) from 6 urban and 5 rural health centers were enrolled in the study. Table 1 lists study participants by position type, title, and practice setting. Results from an analysis of the interviews revealed overarching themes: advantages of participating in community-wide activities and challenges of meeting patient care needs in communities.

Advantages of Participating in Community Activities to Address Social Care and Quality

Several themes emerged from the investigators’ discussion with FQHCs about their involvement in community-wide activities to address social care, quality, and IT infrastructure (Table 2). This section describes the benefits of participating in these activities.

Theme 1: Community workforce development initiatives supported FQHCs. FQHCs often discussed care coordination improvement efforts and community capacity building as key local initiatives to meet patient social needs. Directors and care managers described the strengths of partnerships and shared resources as being advantageous to their involvement in community-wide activities. A quality manager stated, “There is a collaboration among care managers from different practices in the area through a value-based program. And so they are big on sharing resources….” A quality director explained, “There was a speaker from Michigan State University through the Integrated Health Partnership [who] talked specifically about social determinants of health [SDOH].” A community health worker said, “Most of the local coalitions write grants.” A chief operating officer stated, “Some of our partners have applied for grants to help with communication and technology.”

Theme 2: Community-wide activities sustained public investments and FQHC involvement. During our interviews with FQHCs involved in State Innovation Model projects, designed to test care models and IT solutions, we learned that those federal investments were sustained. Various executives described how these projects had evolved to address data and care quality. An executive director explained, “The committee has members from all over the community. They’ve spent a lot of time creating the SDOH needs form to ensure it fits. [That included] the infrastructure to pull the data and gather the information, and then discussions around how we can do better care management, how we can make sure that we are reaching the people [who] need to be reached…are we missing any gaps in care, that type of thing. And so they continue to meet, and it just keeps evolving to identify current needs and resources in the area that can help fill those needs.”

Theme 3: FQHC community participation supported care and quality activities. During interviews with FQHC leadership and staff, they commonly discussed health plan and practice performance measures used to incentivize community engagement and quality activities. A care manager described the financial incentives: “For Meridian [health plan,] we are working on gaps in care reports, high emergency department use, and [SDOH]. And the Healthy Michigan Plan through Medicaid provides patients transportation.” One quality director discussed revenue-generating opportunities through their statewide network of FQHCs: “[Michigan Primary Care Association] has contracted with Molina [health plan] on disparities of care, and payments are tied to whether you reduce some of these gaps.” A CEO summarized their financial strategy: “We have value-based contracts with [multiple health plans]. We also meet different HEDIS [Healthcare Effectiveness Data and Information Set] measures to build in incentives to pay for staff.”

Challenges of Meeting Patient Social Care Needs in Communities

This section describes resource shortages, service gaps, and IT limitations (Table 3).

Theme 1: lack of community resources and services. During the interviews conducted with FQHC leadership and staff, nearly everyone discussed a lack of resources in their respective communities. Limited housing options were identified as a local issue throughout Michigan. A community health worker stated, “Probably the biggest unmet need is housing resources.” A care manager further explained how patients go untreated because of unavailable resources and compounding social problems: “If there’s no housing available and the people don’t have jobs, it does get really difficult to match them up with local resources.” A chief operating officer from another practice even characterized the lack of housing as a major catastrophe: “We have a real housing need. I would call it a crisis.”

Theme 2: inconsistent care and scarce funding. In interviews with FQHC directors and managers, they repeatedly discussed barriers to meeting patient needs in the community. Erratic funding levels, changing eligibility criteria, and limited program capacity were frequently mentioned. A quality manager described poor communication as a reason why patients don’t get the treatment they need: “The biggest gap has always been that follow-up piece.” A care manager further explained the root problem: “You’re not going to find an organization that can help every single person.” A quality director offered additional insight: “You get to these periods of time where there’s just not anything available.” A program director summed it up best: “There is too much competition for scarce funding in the nonprofit world.”

Theme 3: inadequate behavioral health care. In the interviews with FQHC leadership, managers, and care staff, study participants described inadequate behavioral health care throughout Michigan. A social worker from an urban practice said, “There’s no psychiatrist. It’s very difficult to get psychiatry, even in an area like Ann Arbor or Troy [affluent communities in Michigan].” A clinic manager discussed the challenges of providing quality care and offered reasons why patients go untreated: “There have been poor patient experiences with providers due to short staffing and only a few alternatives available.” A director of behavioral health discussed local resource and service gaps, saying, “Lack of recovery support programs and psychiatric services presents barriers for our patients trying to access care in the community.”

Theme 4: limited technology and community expertise. During the interviews with FQHC leadership and staff, study participants repeatedly described a lack of technology and community expertise as challenges to meeting patient care needs. This was particularly evident among FQHCs and their social care partners throughout Michigan. A quality director explained, “The way they document their [electronic health record] does not facilitate the information crossing over and interfacing with our [electronic health record] system.” A population health supervisor asserted, “They don’t have an electronic form yet, so they are only doing the paper form.”A chief operating officer also stated, “A lot of things are still done on paper.” A care manager echoed the IT limitations: “Systems don’t interact at all.”


This study explored the infrastructural and technological factors related to managing social care and addressing quality among Michigan FQHCs and partner organizations. Results showed that FQHC involvement in community-wide activities supported social care data management, digital information sharing, and quality improvements. Michigan FQHCs benefited from the structure of these engagements, forming partnerships and collaborations to address resource shortages, improve care coordination, and monitor quality. During the interviews with FQHC leadership and staff, they discussed the advantages of participating in community-wide activities and opportunities that emerged, such as leveraging grant awards received locally to improve care management and develop information infrastructure. Consistent with the findings of Hughes and colleagues, this investigation confirmed that more research on health care and community initiatives is crucial to better understand and support IT adoption and partnership data activities.5 Findings from this study revealed that shifting to a focus on quality care and data sharing sustained investments (eg, federal demonstration projects) made in local IT infrastructure and secured funding for social care and IT adoption when resources were scarce. But even with new payment systems to incentivize the provision of high-quality care, the lack of local programs and services created barriers for Michigan FQHCs to meet patient social needs in communities.

This study examined the broader societal and structural issues that often overwhelm community organizations and public safety net systems. Study results showed that patients of FQHCs experienced insufficient housing and homeless services, inadequate psychiatric care, and limited substance use disorder community programs. This was evident in both urban and rural practices, creating barriers to addressing patient behavioral health and social care needs. Findings suggested that major investments in public health infrastructure and social services may be more critical than investing in medical care when developing policies for improving quality and outcomes.18 Furthermore, a lesson learned from the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009,19 was that incentivizing IT adoption and data use is not enough to change practice behavior.4,20 Policies that incentivize new partnerships and shared data activities are imperative to support local IT adoption and other practice changes.

The study results also pointed to significant resource and workforce issues, such as staff shortages and turnover. During interviews with FQHC leadership, almost everyone discussed competing priorities and staffing challenges as major barriers to developing financial incentive programs. Nonetheless, Michigan FQHCs found ways (eg, creating new reimbursements and performance measures) to generate additional revenue for the provision of social care. Study findings offered evidence that these efforts afforded FQHCs the resources to hire staff for managing patient care and monitoring quality efforts. Data showed that most Michigan FQHCs leveraged fee-for-service and value-based contracts to support a wider range of social care services and partnership activities. Study results confirmed that contracts with payers were used to address health disparities and improve access to care among homeless populations and other vulnerable groups FQHCs did not serve.

Identifying social needs in medical practice is only the tip of the iceberg for health care organizations. Results of this study revealed challenges that go well beyond linking patients to social care. With an affordable housing crisis, chronic homelessness, mental health parity issues, and a growing opioid epidemic, local health departments and social services are not capable of meeting patient social needs alone. It will be difficult to provide social care and improve quality without major investments in local resources, workforce development, and social interventions necessary to address these larger societal and structural issues. This study’s findings underscore the importance of investing in behavioral health care, housing programs, and other social services to effectively meet patient care needs in communities. Health care involvement in community-wide activities creates opportunities to develop resources, social care services, and IT. Still, new policy priorities are imperative to scale critical human capital and key IT infrastructure.


The scope of the study was limited to the perspectives of FQHCs, which revealed biases in the study findings. There was a general sense that the interview respondents held other sectors of care responsible for the lack of local resources, services, and IT. Future studies should identify the barriers and facilitators to managing social care from the perspectives of government and community agencies. A better understanding of the challenges and opportunities from their vantage point will better inform policies and investments made to incentivize IT adoption for these critical partners. The investigation was conducted during the COVID-19 pandemic, and IT research was not a high priority for FQHCs. This impacted site recruitment and subject willingness to participate in the interviews, therefore affecting the sample size and generalizability.


This study revealed challenges that go well beyond linking patients to community resources and services. The findings underscore the importance of investing in public health infrastructure and social services to address the broader societal and structural issues impacting outcomes. Data demonstrated that FQHC participation in community-wide activities offered structure and processes for developing resources to improve care and quality. New policy priorities are imperative to scale critical services and IT infrastructure that support local care management and data activities.

Author Affiliations: Department of Learning Health Sciences (AMP, JEP, GAP) and Department of Family Medicine (MSK), University of Michigan Medical School, Ann Arbor, MI; now with AMP Consulting (AMP), North Bethesda, MD; Michigan Primary Care Association (FS), Lansing, MI; Department of Electrical Engineering and Computer Science, University of Michigan School of Information (MSA), Ann Arbor, MI; Michigan Institute for Clinical and Health Research, University of Michigan (AB), Ann Arbor, MI; now with Center for Health and Research Transformation, University of Michigan (AB), Ann Arbor, MI.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

This article was prepared by Dr Provenzano in his personal capacity and not in his current role with the Substance Abuse and Mental Health Services Administration. The opinions expressed in this article are the author’s own and do not reflect the official view of HHS or the US government.

Authorship Information: Concept and design (AMP, FS, JEP, GAP, AB, MSK); acquisition of data (AMP, FS, JEP, MSK); analysis and interpretation of data (AMP, FS, GAP, MSA, AB, MSK); drafting of the manuscript (AMP, FS, MSA, MSK); critical revision of the manuscript for important intellectual content (AMP, FS, AB, MSK); statistical analysis (AMP, MSK); provision of study materials or patients (AMP, FS); administrative, technical, or logistic support (AMP, FS); and supervision (AMP, FS, JEP, GAP, MSA, MSK).

Send Correspondence to: Anthony M. Provenzano, PhD, MS, MSW, MPA, AMP Consulting, 5411 McGrath Blvd, Apt 1119, North Bethesda, MD 20852. Email:


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