Greater Flint Health Coalition Social Determinants of Health Standardized Screening Efforts

The Greater Flint Health Coalition (GFHC) is one of five organizations chosen by the Michigan Department of Health and Human Services (MDHHS) to lead the implementation of the State Innovation Model (SIM) within their community. The SIM initiative focuses on the development and testing of multi-payer healthcare payment and service delivery models in order to achieve better care coordination, lower costs, and improve health outcomes for Michigan residents. As the backbone organization for the Genesee Community Health Innovation Region (CHIR), the GFHC is working to leverage cross-sector partnerships that address population health and connect patients with relevant community and social services that address the social determinants of health (SDoH).

Development of a Standard Social Determinants of Health Screening Tool
According to the Robert Wood Johnson Foundation’s County Health Rankings initiative, approximately 80% of the factors affecting health outcomes fall outside traditional healthcare delivery, such as health behaviors, social & economic factors, and environmental factors. The GFHC’s SIM Steering Committee determined that one of the initial steps in addressing this issue was to develop a standardized process for screening patients in Genesee County to identify their individual SDoH needs and begin to address more upstream factors of individual health outcomes.
As a result, the Genesee CHIR “Health Needs Screening Tool” was developed. The screening tool utilizes an evidence-based strategy to assess and engage residents sourced from materials provided by Health Leads while incorporating local input from area residents on the factors impacting their health. Patients are asked questions related to the domains of food, utilities, housing, child care, healthcare access and cost, transportation, literacy, safety, substance use, depression, and clean water access.

Implementation within Genesee County Physician Practices
The screening tool has been adopted and is currently being administered by 27 physician practices, encompassing a total of 94 individual providers, in Genesee County and has been incorporated into practice workflows. As a result of screening efforts by physicians, practice embedded care managers, and community health workers, over 4,000 individual patients in Genesee County have been screened to date. Information gathered from screens allows physicians to gain a clearer picture of the patient’s health status as well as guide care coordination activities in the practice setting and direct the strategy of the SIM Clinical Community Linkage Initiative in how to most effectively connect individuals to necessary resources.
Additionally, through a partnership with Great Lakes Health Connect, all screening results are submitted to a community data repository where they are aggregated into monthly reports. Insights gathered from this unique collection of data on Genesee County residents informs the SIM Project through identifying areas of greatest need in our community as well as gaps in resources and barriers to access.

The physician partner organizations that are involved in this project include Professional Medical Corporation, McLaren Physician Partners, and the Genesee Community Health Center. For more information regarding the State Innovation Model work in Genesee County, or how your practice can get involved, please contact Lori Kunkel, Vice President of Programs, Greater Flint Health Coalition by email at