Health Centers Addressing the Social Determinants of Health

Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)
Background PRAPARE data lays the foundation to achieve goals on many levels.
The objective of this project is to help community
health centers and other providers assess and
address the social determinants of health (SDH) by
creating, implementing, and promoting the
Protocol for Responding to and Assessing Patient
Assets, Risks, and Experiences (PRAPARE). By going
beyond medical acuity to identify patient risks
related to the SDH, PRAPARE positions health
centers and other providers to better understand
and manage their patient populations. PRAPARE
will inform the development of new programs and
partnerships that ultimately improve health
outcomes and curb health care spending.

Project Timeline Accomplishments to Date

 Developed Tool
o Aligned with national initiatives,
including Healthy People 2020
and the Institute of Medicine’s
Recommended Social and
Behavioral Domains and
Measures for the Electronic
Health Records.
o Gathered stakeholder input
o Reviewed relevant literature
 Selected 4 Implementation Teams
through a competitive process and
prepared them for pilot-testing

 Cognitive testing of PRAPARE with

patients:
o demonstrated ease of use
o led to interventions
 Preliminary testing of SDH
assessment in Spanish
 Monthly webinars for shared learning
around best practices and
overcoming challenges

This project was made possible with funding from the Kresge Foundation, the Blue Shield of California Foundation, and the Kaiser
Permanente National Community Benefit Fund at the East Bay Community Foundation.
For more information about this project, please contact Michelle Jester at mjester@nachc.org or visit the “Resources for
Addressing Social Determinants” folder at http://www.healthcarecommunities.org/ResourceCenter.aspx February 2015
 Health Centers Piloting PRAPARE
Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)
Four Implementation Teams consisting of at least one health center and one health center network will participate in a Learning
Community (LC) to pilot-test PRAPARE in 2015. Over one year, the LC will integrate the protocol into health centers’ workflow,
create Electronic Health Record (EHR) templates, and develop interventions to respond to the SDH risks.

Teams reach states across the country,

aiding with the national dissemination
of PRAPARE.
All Implementation teams have a demonstrated history of commitment to addressing patient SDH.
All LC health center sites are certified or pending certification as patient-centered medical homes. Teams have prior experience
collecting and recording data on patient social history and use of enabling services, which help patients overcome non-clinical
barriers to accessing care. Teams have collected data for enabling services such as eligibility assistance and financial counseling,
interpretation, case management, health education, and transportation. This data has been used by LC member organizations
to identify and support the development of needed programs, connect patients with community resources and patient
navigators, target patients for specific screenings, and identify the level of care management a patient needs.

This project was made possible with funding from the Kresge Foundation, the Blue Shield of California Foundation, and the Kaiser
Permanente National Community Benefit Fund at the East Bay Community Foundation.
For more information about this project, please contact Michelle Jester at mjester@nachc.org or visit the “Resources for
Addressing Social Determinants” folder at http://www.healthcarecommunities.org/ResourceCenter.aspx February 2015