Safety Net Primary Care Capabilities After the COVID-19 Pandemic

Importance Federally qualified health centers (FQHCs) provide care to 30 million patients in the US and have shown better outcomes and processes than other practice types. Little is known about how the COVID-19 pandemic contributed to FQHC capabilities compared with other practices. Objective To compare postpandemic operational characteristics and capabilities of FQHCs with non-FQHC safety net practices and non-FQHC, non–safety net practices. Design, Setting, and Participants This nationally representative survey conducted from June 2022 to February 2023 with an oversampling of safety net practices in the US included practice leaders working in stratified random selection of practices based on FQHC status, Area Deprivation Index category, and ownership type per a health care network dataset. Exposures Practice type: FQHC vs non-FQHC safety net and non-FQHC practices. Main Outcomes and Measures Primary care capabilities, including 2 measures of access and 11 composite measures. Results A total of 1245 practices (221 FQHC and 1024 non-FQHC) responded of 3498 practices sampled. FQHCs were more likely to be independently owned and have received COVID-19 funding. FQHCs and non-FQHC safety net practices were more likely to be in rural areas. FQHCs significantly outperformed non-FQHCs on several capabilities even after controlling for practice size and ownership, including behavioral health provision (mean score, 0.53; 95% CI, 0.51-0.56), culturally informed services (mean score, 0.55; 95% CI, 0.53-0.58), screening for social needs (mean score, 0.43; 95% CI, 0.39-0.47), social needs referrals (mean score, 0.53; 95% CI, 0.48-0.57), social needs referral follow-up (mean score, 0.31; 95% CI, 0.27-0.36), and shared decision-making and motivational interviewing training (mean score, 0.53; 95% CI, 0.51-0.56). No differences were found in behavioral and substance use screening, care processes for patients with complex and high levels of need, use of patient-reported outcome measures, decision aid use, or after-hours access. Across all practices, most of the examined capabilities showed room for improvement. Conclusions and Relevance The results of this survey study suggest that FQHCs outperformed non-FQHC practices on important care processes while serving a patient population with lower incomes who are medically underserved compared with patients in other practice types. Legislation to expand funding for the FQHC program should improve services for underserved populations and target current non-FQHC safety net practices to serve these populations. Increased support for these practices could improve primary care for rural populations.