Featured Articles: Quality Improvement

Understanding Patient and Community Social Risk to Drive Care Transformation: The PRAPARE Experience

Monday, September 12, 2016   (0 Comments)
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Alicia Atalla-Mei, Oregon Primary Care Association


Editor's note: Alicia will be presenting on this topic at the Fall Primary Care Conference in Denver on October 18


As the healthcare system increases efforts to improve health outcomes and lower costs of care, it is necessary, perhaps now more than ever, for providers to better understand and have the capacity to address their patients’ social determinants of health. Our ability to mitigate and even reverse the socio-economic causes of poor health is key to improving outcomes and reducing spending.  However the healthcare delivery system has not been designed in a way that supports clinical staff in understanding and addressing their patients’ non-medical health needs.  


In addition, the push towards value based payment places providers at increased accountability for reaching quality targets while lowering costs of care. Community and Federally-Qualified Health Centers are particularly vulnerable in this arena, as they serve 25 million patients at high risk for multiple and compounding social determinants risk factors. As the Community Health Center (CHC) patient base continues to expand, CHCs will serve far more of the nation’s complex, at-risk communities who require a wider range of non-medical services to be integrated into their health care.


To help equip health centers and other providers with the understanding, data, and processes that they need to better manage their patient populations, the National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, and Institute for Alternative Futures have collaborated to develop and test a process for interviewing patients about their social determinants of health, collecting standardized patient-level social risk information, and using that data to affect change at the patient, population, and delivery system levels.


The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool includes validated measures for standardized data collection around twenty social determinants of health.  Project partners used a multi-method approach to develop the tool, including an environmental scan of existing tools, literature review, stakeholder and expert engagement, and alignment with proposed SDH Meaningful Use measures as well as national SDH initiatives such as Healthy People 2020.  Other criteria ensured data collected were actionable, built therapeutic relationships with patients, and were not burdensome.  The PRAPARE tool allows providers to collect more granular data through a sensitive, human-centered approach while still supporting aggregated data collection across providers.  Identified risk factors align with UDS and ICD-10.


In 2015, four health center implementation teams pilot-tested the tool, developed templates to facilitate data capture and reporting in four commonly used Electronic Health Records (EHR), and electronically captured data on nearly 3,000 patients.  Pilot data reveal that most patients face four to nine social determinant risks.  However, chronically ill patients tend to face upwards of eleven social determinant risks.  There is also a positive correlation between the number of social determinant risks a patient faces and having hypertension.


These health centers, and others that also implemented PRAPARE, demonstrated that the tool builds provider-patient relationships, identifies new needs, and can be implemented using different modalities and clinic staff.  We have documented how PRAPARE is helping health centers address social risk by getting to know individuals patients holistically, risk stratifying patients, altering service at point of care to accommodate individual patient circumstances, enhance care management and other programs that facilitate access to clinical and non-clinical services, build new partnerships with community service organizations, and develop new outcomes-driven strategies.  Key implementation resources, action tactics, and lessons learned are being included in a PRAPARE implementation and action toolkit which is currently in development.


The session at NWRPCA’s fall conference will describe the tool development and implementation process; best practices and lessons learned in interviewing, collecting and acting on SDH data at multiple levels; point of service, organizational, and community-level changes that have occurred as a result of PRAPARE; the applicability of lessons learned for all providers; and implications for care and delivery system transformation.  


NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.


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