HIMSS: A Standard Way to Approach the Social Determinants of Health

EMS providers don’t need to be told how social factors can impact their patients’ health. But even most advanced mobile integrated healthcare/community paramedic programs are only in the early days of gathering such data and using it to help shape care plans. 

A new template designed to help community health centers standardize this process may have applicability across the healthcare spectrum. The project was described Thursday at HIMSS by Michelle Proser, PhD, director of research for the National Association of Community Health Centers, and Andrew Hamilton, RN, chief information officer for AllianceChicago, a collaborative dedicated to improving personal, public, and community health. 

Medical care only determines roughly 10% of a patient’s overall health, Hamilton noted; social factors (15%), genetics (30%), and the patient’s individual choices (40%) bear on it more. All told, many upstream socio-ecological issues wield influence, and recent IHI/IOM data suggests that as much as $1 trillion needs transfused into developing community supports for such patients. But misaligned incentives deter investment, and healthcare workforces often aren’t competent in addressing social needs. 

PRAPARE—the Protocol for Responding to and Assessing Patients’ Assets, Risks, & Experiences—was designed to accelerate systemic population health improvement. Its basic idea is that by cataloguing and scrutinizing patients’ community contexts, we’ll understand them better and can transform their care through redesign of its delivery system. It’s not a study, Hamilton, stressed, but is “meant to be an on-the-ground framework.”

Community health centers represent the U.S.’ largest national network of primary and preventive care, serving more than 27 million patients from more than 10,400 sites. Their clients are heavily low-income and uninsured, including around 1.3 million homeless and 965,000 migrant farmworkers. Federal requirements for CHCs go beyond just medical care into other areas and broader case management, so addressing SHDs (social determinants of health) is within their purview. They have now been reporting clinical quality data for nearly 20 years. 

The PRAPARE effort began with foundation funding in 2014 that fostered development of domain-selection criteria and a basic paper tool. The next year it was piloted in EHRs, and full implementation followed in 2016, along with an action tool kit. That means the protocol is still new, Proser observed, having only been in use for roughly a year and half. But it’s already generating widespread interest, including beyond CHCs. 
PRAPARE has 14 core and six optional domains to ask about. Of the core domains nine overlap with the uniform data system used in federal health center reporting; the other five are informed by Meaningful Use Stage 3 requirements:

Core/UDS domains

• Race
• Ethnicity 
• Veteran status
• Farmworker status
• English proficiency
• Income
• Insurance
• Neighborhood
• Housing

Non-UDS domains

• Education
• Employment
• Material security
• Social integration
• Stress

Optional domains

• Incarceration history
• Transportation
• Refugee status
• Country of origin
• Safety
• Domestic violence

Where, when, how, and by whom in the process these are to be asked is left to the user. They can be investigated electronically but are meant to engage the patient. What’s meant to be standardized is the need/risk rather than verbiage. NACHC has already developed templates incorporating the domains for four major EHR vendors (Epic, NextGen, eClinicalWorks, and GE Centricity), with more on the way. 

A 2015 pilot found that subject patients typically had 4 to 7 social risk factors, excluding low income and clinical factors, and that the tool was easy to administer (taking on average 5-8 minutes) across various workflows and staffing models. Users found it facilitated collaboration and relationship-building with partners. 

And already it’s informing changes: In Sioux City, health authorities kept running out of taxi vouchers to get transportation-challenged patients to appointments. After PRAPARE helped document these travel issues, the city is now working on rearranging bus routes to serve these patients better.

For more, see www.nachc.org/research-and-data/prapare/.