Health care providers and government agencies can benefit from knowing more about the communities they serve. They can address issues unique to low-income patients and other groups with specific needs, improving outcomes and lowering medical costs. Using a data-driven approach to public health, they can successfully implement targeted health interventions, while lowering costs. We hear from two practitioners and researchers who will talk about ways that they’re using community level data to improve public health: Sarah Dixon from the Iowa Primary Care Association and Amy Carroll-Scott from Drexel University’s Dornsife School of Public Health.

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Treating the Whole Community:
Addressing Social Drivers of Health

2. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Sarah Dixon, MPA
Senior Director for Emerging
Programs, Iowa Primary Care
Association

3. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Protocol for Responding to & Assessing
Patients’ Assets, Risks & Experiences:
A national standardized patient risk assessment
protocol designed to engage patients in assessing &
addressing social determinants of health (SDOH).
PRAPARE = SDOH screening tool +
implementation/action process
Customizable Implementation and Action Approach
Assess Needs Respond to Needs
→
At the Patient and Population Level

4. Treating the
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Community:
Addressing
Social Drivers
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4
PRAPARE Domains
Spanish and Chinese
(Mandarin)
translated versions
Core
UDS SDOH Domains Non-UDS SDOH
Domains (MU-3)
1. Race 10. Education
2. Ethnicity 11. Employment
3. Veteran Status 12. Material Security
4. Farmworker Status 13. Social Isolation
5. English Proficiency 14. Stress
6. Income 15. Transportation
7. Insurance 16. Housing Stability
8. Neighborhood
9. Housing Status
Core +
1. Incarceration
History
3. Domestic
Violence
2. Safety 4. Refugee Status
Core + Granular
1. Employment:
How many
hours worked
per week
3. Insurance: Do you
get insurance
through your job?
2. Employment: # of
jobs worked
4. Social Support:
Who is your support
network?
Source: http://www.nachc.org/wp-content/uploads/2016/08/Chapter_1-Understand_the_Project_Sept2016.pdf

5. 5
PRAPARE Impacts
Patient and Family
Care Team Members
Health Center
Community/Local
Health System
State and National
Policies
Individual
level
Organizational
level
Payerlevel
Empowered to improve health and wellbeing
Better manage patient and population needs
Design care teams and services to deliver
patient/community-centered care
Integrate care through cross-sector partnerships,
develop community-level redesign strategy for
prevention, and advocate to change local policies
Execute payment models that sustain value-based
care (incentivize the social risk interventions and
partnerships, risk adjustment)
Ensure capacity for serving complex patients,
including uninsured patients
System/
Community
level
Payment
Policylevel
Source: http://www.nachc.org/wp-content/uploads/2016/08/Chapter_1-Understand_the_Project_Sept2016.pdf

6. Treating the
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Addressing
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of Health
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PRAPARE National Partners

7. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Our Vision and Interest
• Provide better care to patients
– Collect more robust data about other factors impacting
health
– Begin to match identified issues with solutions with the
health center
• Use data to establish or grow partnerships
with other community resources
• Leverage data and accompanying
interventions to provide evidence to payors
and policymakers about the needs of
patients, a broader definition of patient risk,
and to ensure adequate reimbursement for
safety net providers

8. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Benefits of Universal SDoH Screening :
• Demonstrate the complexity of all patients served
by FQHCs
• Analyze differences within patient population to
help explain varied health outcomes or behaviors
• Evaluate the need for community-based
interventions
• The power of data- influence policy makers and
payors
• Be upstreamists- proactively intervene to prevent
future health issues
• If you don’ k, you don’ lw y know
“To reen, or no o reen, i
e que ion.”
-William Shakespeare

9. Treating the
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Community:
Addressing
Social Drivers
of Health
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Network Data Strategy for SDoH
• Multi-tenant database
– All GE Center data in a common repository w/ role-based
security
• Tableau visualizations of aggregated data at center level
• More granular data (patient-level) for individual centers
• Initial functional requirements for network- and clinic-
views documented and wire-framed
• Performance measures
– PRAPARE items that prompt for problem-li en rie …no
added to problems list
– Items that prompt for further assessments (e.g., social
isolation/depression) not completed
– Number/proportion of patients in a given cohort that have had
a PRAPARE assessment in last 12 months.
– ???

18. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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19. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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20. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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21. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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-webinars

22. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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23. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Impact of SDoH on DM and HTN
Preliminary results
• Logistic model results:
1. For every one increase in the PRAPARE risk tally score, the probability of
being an uncontrolled diabetic patient increased by 13% (p-value =.07)
2. Compared to patients who didn't have trouble affording medicine/care,
patients who had trouble were 78% more likely to have uncontrolled
diabetes. (p-value < 0.05)
3. Compared to patients who were not stressed, patients who were stressed
were 41% more likely to have uncontrolled hypertension (p<.05)

24. Treating the
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Community:
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Social Drivers
of Health
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Impact of SDoH on Diabetes
Preliminary results
• Compared to controlled diabetics, uncontrolled diabetics had significantly
higher rates of the following PRAPARE SDoH domains (p<.05):
SDoH
Controlled
DM
Uncontrolled
DM SDoH
Controlled
DM
Uncontrolled
DM
Lack of
housing 7% 11% Utilities need* 8% 10%
Worry about
housing 6% 10%
Transportation
need* 14% 18%
Food
insecurity 11% 17%
Legal aid
need* 4% 6%
Phone needs 7% 10%
Childcare
need* 1% 3%
Stress 46% 55% Safety need* 4% 7%
Challenge
with
accessing
care 15% 28%

25. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Future Opportunities
• Documenting enabling services to validate to payers and policy makers
need for funding and for internal justification
• Identifying most common determinants and determining best ways to
address
– Bolster or create in-house services
– Develop or strengthen and external partnerships
– Partner with others to create
– Coordinate with policymakers and community stake holders to address social and
environmental conditions
• Cross tab survey results with clinical indicators such as chronic
diseases
• Think about staffing needs at the health center and further community
partnerships needed to connect patients to necessary interventions
• Build these necessary interventions into the overall care coordination
approach at health centers
• Using the data as part of PCMH re-recognition process
• Risk coding to inform payers of complexity of patient
– Have accomplished some alignment with Iowa Medicaid around a 3M product and
overall approach through CMS SIM Model Testing funding, adding PRAPARE
questions to their HRA

26. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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UPSTREAMIST
Rishi Manchanda, MD, MPH, Founder of
HealthBegins
“T ree friend ome o river filled wi people
helplessly being swept toward a waterfall. The
first friend jumps in and furiously tries to save
people who are just about to drown. In an effort
to improve the rescue rate, the second friend
builds a raft to ferry more people to safety.
W ere’ e ird friend? T per on i looking
upstream, to prevent people from falling in the
river in the first place. Upstream is where more
e l re provider need o go.”
(From a new IHI Open School video short)

27. Treating the
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Community:
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Social Drivers
of Health
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THANK YOU!
Sarah Dixon, MPA
Senior Director
Iowa Primary Care Association
sdixon@iowapca.org

28. Treating the
Whole
Community:
Addressing
Social Drivers
of Health
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Treating the
Whole
Community:
Addressing
Social Drivers
of Health
#mapchats
policymap.com/mapchats
-webinars
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