The Importance of Screening for Social Determinants of Health

In this episode of the AMA STEPS Forward® podcast, Margaret Bavis, DNP and assistant professor, Rush University College of Nursing, discusses how CommunityHealth, one of the largest volunteer-based health centers in the nation, assesses and optimizes social determinants of health to improve patient care. 


  • Margaret Bavis, DNP, at CommunityHealth in Chicago and assistant professor, Rush University College of Nursing


  • Jill Jin, MD, MPH, senior physician advisor with AMA STEPS Forward®

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Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We’ll hear from health care leaders nationwide about real world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA’s Steps Forward program is open access and free to all at

Dr. Jin: Hello, everyone and welcome. This is Dr. Jill Jin, senior physician advisor with the AMA STEPS Forward® team, and I am your host for today. Today on the podcast, we are joined by guest Margaret Bavis, a nurse practitioner who has her doctorate in nursing practice and currently practices at CommunityHealth in Chicago. She is also an assistant professor at Rush University College of Nursing. Our topic today is how CommunityHealth assesses and optimizes patients’ social determinants of health and how this has helped their patient population. Margaret, thank you so much for joining me today.

Bavis: Thank you so much for having me. Happy to be here.

Dr. Jin: Why don’t we start with you telling the listeners a little bit more about yourself and your background.

Bavis: Sure. As you mentioned in the introduction, I’m a nurse practitioner and assistant professor at Rush University College of Nursing. I have a clinical practice at CommunityHealth, which is part of an academic practice partnership between CommunityHealth and Rush University’s College of Nursing, and I primarily train nurse practitioner students at CommunityHealth.

In addition to my clinical training program, I also teach in Rush’s Doctor of Nursing Practice, Family Nurse Practitioner program. I direct our clinical simulation program, which is heavily informed by my clinical work at CommunityHealth. I’ve been an NP for over 20 years. I’ve worked in a variety of settings. My professional interests are around NP student training and working with under-resourced communities and in clinical reasoning. This year, I was selected for a fellowship with the Society for Diagnosis in Medicine, and I’m working on how to better assess diagnostic reasoning in NP students. I am also a wife, mother of three and, in my free time, I have been studying Spanish.

Dr. Jin: Wow. I was just going to say what free time, but.

Bavis: Exactly … it feels that way.

Dr. Jin: Can you tell us a little bit more about CommunityHealth specifically? What it is, who it serves and what the mission is?

Bavis: Absolutely. CommunityHealth really is a phenomenal place and probably many of your listeners may have had some and, if they’re in the Chicagoland area, may have crossed through the doors of CommunityHealth as a volunteer or a trainee at some point. It was established in 1993 by a physician, Dr. Serafino Garella. He was a nephrologist and, prior to starting CommunityHealth, he was wondering why so many patients were reaching him in end stage renal disease and why they had lacked care for the prevention and management of their preceding chronic diseases.

In identifying this problem, he identified a gap in our system that patients without access to health care, either via private or public insurance, had no access to these preventative and chronic disease management. He brought together some colleagues and they opened the first CommunityHealth site. It started as a small storefront clinic but it has grown, over these past close to 30 years, to a fully functioning comprehensive health center with a central location that houses 15 exam rooms, a dental suite, a full pharmacy that provides a 90 day supply of medications to the patients, full laboratory services, health education, counseling, again, all free of charge.

In addition to this main site, they also, in the last two years, which is amazing because, yes, during the pandemic, opened two innovative microsites that partner with community based agencies to provide both in-person and augmented telehealth services to patients. CommunityHealth has a unique model that brings together volunteers, donors, community partners to serve thousands of Chicago’s uninsured adults. It has a small core staff of 45 and then over 1,000 volunteers, which includes physicians, specialists, residents, pharmacists, nurses, nurse practitioners, med students, pharmacy students, nursing students, interpreters and lab techs. Basically, everyone. It provides high quality health care, serves as a patient-centered medical home to more than 4,000 patients annually and provides services six days per week.

Dr. Jin: Wow. What a great story. I mean, it sounds too great to be true, almost, what you’re describing. Of course, the natural question is, what you alluded to, is how is this all funded? I know you said it’s largely volunteer based in terms of the staff and the providers. What about the operating costs?

Bavis: Sure. Again, since it does rely so much on the huge base of volunteer, primarily providers, that core staff of 45 and the facilities are funded through grants and donations. They really have figured out how to maximize finances and really trim to the core essentials that are needed for running the clinic. And then these extensive partnerships that CommunityHealth has with the major medical centers here in the Chicagoland area really facilitates a lot of the additional care, be it referral for specialty services or diagnostic tests. They’ve established a pretty extensive network of partnering agencies to provide those free of charge.

Dr. Jin: Wow, that’s phenomenal. And then, of course, with that patient population, there are lots of these social determinants of health issues that are a topic for today. I do know that CommunityHealth did identify that area as an important area of exploration in their recent strategic plan. Can you tell us more about what that means on a practical level?

Bavis: Absolutely. CommunityHealth really has a clear mission to serve people without essential health care. The services, again, as I mentioned in the introduction to CommunityHealth, currently targets that gap in our system for those who cannot afford or don’t have access to private or public insurance. All of our patients are low income, at or below 300{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} of the federal poverty guidelines. Most are immigrants, so many who carry a history of trauma and have had little access to primary care previously. As you can imagine, addressing social determinants of health is at the core of our provision of care to our patients. This involves considering the whole patient, the setting in which one lives and works, the individual challenges of day-to-day life, as well as the personal needs and priorities of the patient.

On a practical level, that means understanding, for example, a patient’s work schedule and how it might impact their ability to take their medications consistently. For example, a multi-dose insulin regimen, understanding living conditions and how that may impact illness. For example, home isolation during COVID in multi-generational homes with only one bathroom. Understanding access to food and physical activity when considering counseling on lifestyle.

In addition, many of our patients speak a language other than English, so we also have volunteer interpreters to remove the challenge of that language barrier. All of our printed materials are available in either Spanish or Polish, which are the predominant languages that are spoken amongst our population. But for many patients, this is the first clinic space where they feel their specific needs are taken into consideration, and I think it is because of the thoughtful approach to social determinants of health.

Dr. Jin: Are those questions and issues, are they just brought up during a first visit or is there a formalized intake process to identify the needs?

Bavis: There is a process, and I would say it falls a little twofold. For every patient that is registered at CommunityHealth, they do fill out a formal social determinants of health screening or screener similar to what listeners may be familiar with in other practice sites or in the hospital setting. And then that document is uploaded into our EMR and reviewed by the social worker who oversees all of the social determinants of health screening, but it’s also available for reference by providers and also integrated then, we can integrate that into our encounters or visits with our patients to identify if this is somebody who doesn’t have access consistently to foods. We might connect them to a food bank. Or if there are some other issues in terms of housing, safety, we could connect them with a social worker to try and remediate that.

But once a patient screens positively, it’s either addressed by the social worker and/or the provider. One way we do that is through a program called NowPow. Again, another pretty innovative project started by a physician, Stacy Lindau, who identified a need. But it’s a personalized community web-based referral platform where it will match social service agencies or resources directly to a patient by their zip code and address. So we can create a customized referral list for patients or resources close to their home based on what needs have been identified either in our conversation or on the screener.

Another way is through this creation of the microsites. The two microsites that I mentioned were actually established within community organizations in different zip codes that we recognized as being some of the largest holes for our patient population. And so, CommunityHealth partnered with social service community organizations within those communities and zip codes to establish this microsite so that they could connect patients to health care, but also keep them within a site that provided other resources. For example, ELL classes, immigration resources, different programming like that exist at the sponsoring agencies that our microsites are now housed in.

Dr. Jin: Does this level of outreach and planning happen pre-visit or is it during a visit or just ongoing?

Bavis: Sure. In terms of the formalized screener, that can be addressed separately outside of the visit. Somebody screens positive on one of the components of the screener, the social worker can produce resources and reach out to the patient and connect them with resources either via NowPow or through one of our sponsoring agencies. Outside of that, a lot of our social determinants of health comes through our holistic approach as a clinic to the patient, and so that is something that happens pretty organically during our visit.

I would say that the culture of CommunityHealth amongst providers is to be very patient-forward and prioritize understanding the whole picture, in simple things like when you’re doing a history and getting a good social history of where somebody works and what kind of work they do and how many jobs they have to have or what their living arrangements are like and what their environment that they’re living in is. Are they in a basement apartment that has water damage and mold and that’s perhaps contributing to their reactive airway or asthma presentation? Or is it about when you’re talking about healthy eating and what resources somebody has for fresh fruits and vegetables? We kind of address it in both ways.

Dr. Jin: These topics are so important and, like you’re saying, it’s the going upstream and just finding out the root of their reactive area disease instead of our often traditional approach of just treating it. I am curious how long you have for each patient appointment.

Bavis: That’s always the tricky one. CommunityHealth is a huge training site. That’s part of the huge volunteer base is that there are a lot of different training programs run out of there. For example, I’m overseeing the nurse practitioner training program. Pretty much every med school in the city has a med student clinic. Many of the hospitals have a residency clinic, and so the time allotment really depends on your training program and what year you are in your training program.

But the vast majority of our slots are 30 minutes, and that seems very generous if you’re coming from private practice or the FQHC world. But you have to remember that our patients, we also have to, oftentimes, use interpreters. Secondly, that many of our patients have not had access to health care for a very long time so there’s a backlog of concerns that need to be addressed, and part of the whole social determinants of health component is building that trust with patients so that they will share those needs with you so that you can properly address them and partner with them. It’s a 30 minutes that goes by really, really fast.

Dr. Jin: I don’t think it’s generous at all. I think it’s actually ambitious. I feel like I would need 45 or an hour. But you’re right, it’s the trust component that it takes time to build and it’s essential to do that, to take the time to do that. I’m sure you have many patient stories and anecdotes about how impactful this has been. Are there any that you could share with us?

Bavis: Absolutely. Just in preface to that, I think one of the important things to remember and why I think some of the really impactful stories that we have are because of the model of CommunityHealth, but because its intention is to provide comprehensive health services free of charge to some of the most vulnerable patients, it also looks on building long-term relationships between patients and a primary care provider.

Despite the fact, I know I had mentioned that we have a lot of training programs, there’s a huge effort to try and make sure that patients have a continuity provider that they stay with over time. What that has meant for me, as a provider, I’ve been at CommunityHealth for close to nine years. My time there, I see patients 16 hours, about two full days a week, and my panel is, last time I checked, I’m at 285 patients for my panel and most of those patients I have been seeing consistently for nine years. That really changes some of the relationship building and really what we can do with patients over time.

Obviously, I’ve lost patients too when they are able to access health care, which I’m always happy, happy, happy for that or for those who have returned back to their countries of origin. But I think that main focus of trying to create a safe space and a place of trust is really essential. Many of my success stories come from that.

I think the most important thing about understanding the role of a clinic or a health center like CommunityHealth is what it does for the rest of the health care system. By providing this free and consistent care to our patients, we end up saving area hospitals. I think the recent status is close to $9 million annually because we helped to keep patients healthy and out of the emergency department for unmanaged conditions. During the pandemic, that was really super prevalent because we were one of the few places in the community that stayed open for in-person visits for so many of these vulnerable patients.

My stories generally center around either chronic disease or identifying something early and getting somebody quickly to care. But my first story is about a patient who came to me with very poorly controlled Type 2 diabetes and had been suffering with chronic pancreatitis. She had, unfortunately, shown up in the emergency room, been hospitalized several times before she came to me. What essentially was at the root of this was that she was resistant to starting insulin. She didn’t trust health care providers. She felt people weren’t listening to her. She had a pretty suspicious approach to most people that she met, but it was one of my greatest success stories that I was able to partner with her and get her started on insulin. It has really dramatically changed her life and kept her out of the hospital for now two years. I feel pretty good about that.

Dr. Jin: How many visits with her did you have before she agreed to start on insulin?

Bavis: Sure. I have a philosophy that I’m never looking at things as just one time visits, and I think that’s my joy of being a primary care provider that I always am strategically planting and planting seeds. It took me actually not too long, it’s two to three visits because I think part of what was missing is that it was very clear from a health provider standpoint to see that she was hyperglycemic. She was losing weight. She had all of the polys, polyuria, polydipsia, polyphagia. She was losing weight. It was very clear that her problems were coming from her uncontrolled diabetes. But, for her, all she could experience was this chronic epigastric pain, and that’s really all she wanted to talk about. My approach was to validate what was going on with her epigastric pain and then come up beside her and say, “Let’s work on that and this at the same time.”

The big success was just having somebody say, “Yeah, I validate you. You have been very uncomfortable and in a lot of pain and suffering.” With that, I was able to get her just to try, first, “Let’s just try a baby dose and see if that works while we’re also working on managing your abdominal pain.” That was a very feel good moment for me. When her weight started to come back up, it’s one of my great joys every time I weigh her. She’s no longer under 100 pounds.

And then, the other story is really about screenings and prevention. I had another patient come to me within the last year who had actually been turned away from, unfortunately, from an ED in the area. Again, another person presenting with abdominal pain. When I examined her, she had splenomegaly. It was a pretty dramatic finding to find in primary care, and I was able to urgently get her connected. I got her an urgency team through our partners, and we got her urgently connected to another partnering hospital for care. And so, they were able to diagnose her lymphoma and get her started on treatment. Currently, she’s doing much better but, obviously, we’ll see how it goes. But I felt that was a good example, too, of some of the sadly typical things that we deal with at CommunityHealth.

By no means do I think that I have any of the special sauce in any of this. Really, all the providers, if you speak to any provider at CommunityHealth, they all have stories similar to the ones I just expressed. I think it’s just a reflection on the kind of person who practices there and the kind of environment that we’re in where we’re really very, very patient-focused.

Dr. Jin: Wow. Thank you for sharing those. I think your point about the trust and the importance of the longitudinal follow up is just so key. My question about the number of visits, that was a leading question because if it doesn’t happen on the first or second, or maybe not even the tenth visit, but it’s just about slowly building that relationship, and then the goal is that ultimately pays off.

Bavis: Yeah. I absolutely saw that too during the pandemic. I think everybody knows how hard the pandemic has been. Definitely, when we started shifting gears and finally had the vaccine, we all were taxed with an uphill battle against a lot of misinformation. I really cashed in a lot of my trust with my patients. I’m not normally pretty forceful about things but having spent nine years with people, I felt this was our chance to say, “This is really something that’s going to save your life despite what you’re hearing from the TV or from people in your community.” That, I think was a huge, huge asset that I did have those longstanding relationships and I had been there through their previous trials and tribulations with their health and wellbeing that it served us in that context. We can never undervalue the role of a primary care provider in somebody’s life.

Dr. Jin: Yes, totally. I’m curious. Do you ever have patients who, like you said, if they get acquire health insurance through employment or not, do they stay with you? Is that allowed?

Bavis: Unfortunately, currently, my only practice is at CommunityHealth because the remainder of my time is spent teaching, so it’s actually a sadness for me too. They do often ask and try to see if they can see me somewhere else but, unfortunately, our charter is so specific at CommunityHealth that we can no longer see somebody once they have insurance. Otherwise, the whole funding, the delicate funding balance, would not be sustainable. It’s always a great compliment. I really appreciate that, and I really enjoy getting letters back from their providers that they go onto.

And then, that’s been a few of our great success stories too, is when I get thank you letters back from, I had a patient several years ago who her husband had lost his job, so they had lost their insurance. She was Type 2 diabetic, had already had an amputation, and she came to me and was really struggling getting to her goal A1C and we were able to work on it together and get her to goal. When her husband got insurance again and she left us, she told her provider, who had been her provider pre-coming to CommunityHealth about her time with me, and the provider sent me just the most lovely letter thanking me.

I just felt that that too is what it’s all about. We’re all part of the same journey with our patients, and I just felt so happy that I could be a part of that patient’s journey. I think it’s nice to remember that. I think we can be so disconnected so many times between hospital to clinic to specialty to whatever. I really feel like that human connection, even for us as providers, to remember that we’re all on the same team, even if we’re at different points in this patient’s journey. It was just really nice. I really appreciated it.

Dr. Jin: I love that. And then, one other thing you mentioned briefly that I want to touch on again is, you said you work two clinic days a week and that your patient panel is 285 patients, which I just think that’s probably a key part of why you’re so good at what you do is just not having an over populated panel. For most institutions or many large academic medical centers, I think it’s something like 1,700 patients for a five day full-time work week for primary care, which is kind of unsustainable. That ratio that you’re describing seems a lot more conducive to that kind of relationship that you’re talking about.

Bavis: Oh, absolutely. I mean, I think that the interesting thing about CommunityHealth and on a health policy level is that, oftentimes, I’ll be having conversations with other providers there about how it really is, how health care should be. It sounds funny to say that about a free and charitable clinic, but I feel like we prioritize the patient and the complex needs of the patient. We are thoughtful about referrals and diagnostics.

One of the big things that comes up every year is whenever we get a new grouping of students or residents or what have you who are used to being able to order an order set inpatient and everybody with right upper quadrant pain immediately gets an ultrasound, we have to be super thoughtful about it because we don’t have unlimited resources in that way. I find it, as a teaching point, really great because it forces my students to have to tell me exactly what it is they’re expecting to find from this test and how it will improve this patient’s care.

I’ve practiced in FQHCs and had crazy panels before and it’s really nice to be somewhere where I feel like I can really get to know people and follow up with them much more consistently. Again, the way the patients react and respond is the truth of the matter. They don’t want to leave us. I’ve had people who cry that they now have insurance and have to leave because, or when I try and encourage them because I think their level of complexity would do better trying to get charity care at a major medical center and they don’t want to go because they feel safe and comforted and well cared for in our setting. I wish we could take this model and really think about how it could help inform things that we’re doing on a bigger scale.

Dr. Jin: Going back to specifically social determinants of health, how can other organizations, large or small, get started on trying to tackle some of those issues? Any practical advice that you could offer those practice leaders?

Bavis: I mean, I always think the moral of the CommunityHealth story is Dr. Garella because here is this individual, the field can feel very overwhelming and isolating to be out there taking care of patients and that being able to stem the tide of all these very, very ill patients. He took that step to try and find out what was at the core of the problem in identifying the core of the problem, which was a social determinant of health, which was access to health care. He was able to develop this clinic model all around that, addressing that core social determinant of health.

My vision and hope for other health care providers is that we’re always looking for that opportunity to address the core fundamental issues because, many times, if we don’t keep looking, these disparities are just going to keep growing. I think looking for root causes of problems for patient populations and then having a real clear vision, a passionate team, you need to have senior leadership buy-in. There’s some core components to getting something off the ground and clear goals and objectives. I think CommunityHealth has kept their mission very straightforward and that has led to being very successful.

It really reminds me though, I was thinking about it, about the Margaret Mead quote, “Never doubt that a small group of thoughtful, committed citizens can change the world.” I feel like that is exactly what happened in CommunityHealth. What started off as this small thing grew to, really, something that changed the world for many, many people, many of the patients that have crossed through our doors.

Dr. Jin: All right. Thank you so much for joining me today, Margaret, that you are so insightful and so wise and such a good diagnostician.

Bavis: Thank you. Well, it was really great to be here. I really appreciate the invitation and the opportunity to come share some of the amazing work that’s going on at CommunityHealth. I really encourage anyone who’s interested in volunteering or wanting to learn more about it to head on over to our website, or reaching out to the clinic itself to see about volunteer opportunities.

Speaker: Thank you for listening to this episode from the AMA’s STEPS Forward® podcast series. AMA’s Steps Forward program is open access and free to all at STEPS Forward® can help put the joy back into medicine by offering real world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series,

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.