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.

PROGRAM

What We Do

Redwood Community Health Coalition established a SDOH/Health Equity Workgroup in December of 2016. This workgroup meets every other month and aims to enhance the ability of member health centers to collect social determinants of health (SDH) data and connect clients to support and programs to address needs.

RCHC convenes a bi-monthly SDOH/Equity Work Group to:

  • Make health equity a strategic priority
  • Develop structure and processes to support health equity work
  • Deploy specific strategies to address multiple determinants of health on which health care organizations can have a direct impact
  • Decrease institutional racism within RCHC member organizations
  • Develop partnerships with community organizations

Next Steps for 2019 & Beyond

  • Continue spreading the Protocol for Responding and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) uptake across health centers
  • Implement NorCalResources.com for health centers to utilize the resource directory and initiate patient referrals to social programs.
  • 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

MEASURES & GUIDELINES

PRAPARE tool

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.

PROJECT CONTACT

For more information, please contact Michelle Rosaschi

ALIGNMENT WITH OTHER INITIATIVES

  • HRSA Health Center Controlled Network (HCCN) Grant
  • County Medical Services Program (CMSP) Grant
  • Whole Person Care
  • Preventing Heart Attacks and Strokes Everyday (PHASE)
  • Regional Behavioral Health Integration Project funded by Well-Being Trust

ADDITIONAL RESOURCES AND COMPANION DOCUMENTS