WHAT are Social Determinants of Health (SDOH) and WHY are they important?

RCHC aims to improve the care of patients with complex social needs by adopting a standard model for assessing and addressing patients’ social determinants of health.

There is a growing recognition that a broad range of social, economic, and environmental factors (such as lack of employment, housing instability, social isolation, and/or food insecurity) shape individuals’ opportunities and barriers to engage in healthy behaviors.

Research indicates that social and environmental factors actually have a greater impact on health and wellbeing than healthcare alone.

SOURCE: Schroeder, SA (2007). We Can Do Better—Improving the Health of the American People. NEJM. 357:12218. Image by Kaiser Family Foundation.


What We Do

Redwood Community Health Coalition established a SDOH Workgroup in December of 2016. This workgroup meets every other month and aims to enhance the ability of member health centers to collect SDOH data and address patients’ SDOH needs in a standard way.

  • Goal #1: Implement a standard Community Resource and Referral Platform for health centers to utilize for patient referrals to social programs by January 1, 2019.
  • Goal #2: By summer 2019, all RCHC HCCN health centers will utilize the PRAPARE tool to systematically screen patients for SDOH needs.

Recent Successes

In 2017, we completed a 6-month assessment of five different community resource and referral platforms. Additionally:

  • 7 FQHC’s implemented the PRAPARE tool
  • Over 2,000 PRAPARE questionnaires were completed; and
  • 6 health centers pilot tested a potential community resource and referral platform.

Next Steps for 2018 & Beyond

  • Continue spreading PRAPARE uptake across FQHCs
  • Contract with and implement new resource directory/referral system
  • Develop strategic partnerships with social service/community organizations
  • Make PRAPARE data actionable at both the health center and coalition level
    • Layer SDOH data over clinical and claims data to identify opportunities for interventions targeting medically and socially complex patients
    • Incorporate SDOH data into patient risk stratification models
    • Use GIS-mapping to identify areas where SDOH “clusters” exist
    • Leverage data for grant opportunities around whole person health, upstream investments, and community partnership opportunities
  • Secure funding to hire a .5FTE to 1.o FTE Project Manager to focus on this work



The PRAPARE assessment tool consists of a set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS). PRAPARE emphasizes measures that are actionable.

RCHC health centers have identified the “core questions” of the PRAPARE tool as the standard model for querying patients about their social determinants of health.


For more information, please contact Michelle Rosaschi


  • RWJ Foundation Complex Care Program
  • HRSA Health Center Controlled Network (HCCN) Grant
  • CMSP Grant