The National Association of Community Health Centers, Inc. (NACHC), Association of Asian Pacific Community Health Organizations (AAPCHO), and Oregon Primary Care Association (OPCA) partnered together to develop, test, and spread a national, standardized, patient-centered social determinant of health (SDOH) assessment tool and companion Implementation and Action Toolkit known as PRAPARE (The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences).

PRAPARE team focused on development of SDOH domains, selection criteria, and paper tool. This involved designing PRAPARE and planning for stakeholder-engaged testing.  There was alignment with Healthy People 2020, ICD-10, Meaningful Use Stage 3, etc. The criteria included burden of data collection, actionability, and sensitivity. All of this was driven by the experience of existing protocols, stakeholder feedback, and literature reviews. In the end, PRAPARE identified 15 core social determinants of health domains.

PRAPARE implementation pilots begin in select electronic health record (EHR) systems to explore data utility. The pilot EHRs include: eClinicalWork, Epic, GE Centricity, and NextGen

PRAPARE Implementation and Action Toolkit is developed to support spread and scale of SDOH screening and assessment efforts

PRAPARE launches its first ever PRAPARE Train the Trainer Academy to support the rising demand for training on PRAPARE implementation and use.  The PRAPARE Train the Trainer Academy is designed to build the capacity of health center member organizations (whether state Primary Care Associations and/or Health Center Controlled Networks) to support their own health center members in PRAPARE implementation and using that data to accelerate care transformation, community investment, and policy, payment, and delivery system changes.

PRAPARE Innovation and Engagement Awards – Round 1 were launched. During the award periods, the PRAPARE team worked with the awardees to learn from their unique uses of PRAPARE SDOH data, including innovative models, replicable strategies, and lessons learned that were packaged into case studies and disseminated nationally.

PRAPARE Train the Trainer Academy Round 2 launches to ensure continuously support new states and effectively promote shared learning across the country.

PRAPARE Innovation and Engagement Awards – Round 2 were launched.

U.S. News & World Report highlighted how health centers are using PRAPARE to improve patient and community health in an article titled “Screening for Social Problems”.

Launched a PRAPARE Twitter (@PRAPARE_SDOH) account to ensure communication and dissemination of key resources

Public News Service wrote an article and produced a podcast that featured a health center in Ohio (Compass Community Health) and their use of PRAPARE in addressing the needs of their complex patients in the midst of the opioid epidemic and their focus working with their pediatric and adolescent populations.

PRAPARE is the most commonly used social needs screening tool by Medicaid managed care organizations across the country according to the 2019 Annual Medicaid Managed Care Survey.

A JAMA study looking at provider screening for social determinants found that health centers were more likely than hospitals and other providers to screen for social needs, and that PRAPARE is likely one reason why.

PRAPARE’s first peer review article published “Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation”. The PRAPARE team worked with health centers and academic partners to analyze outcomes data of patients with varying numbers of socioeconomic needs.

According to 2020 UDS Data, PRAPARE was the most widely-used standardized social risk screening tool among health centers during COVID-19. Throughout the pandemic, the PRAPARE team engaged users in listening sessions and written calls for information to better understand how health centers and their stakeholders have used PRAPARE during COVID-19 to assess and address growing social needs. This led to the development of publications, webinars and training and technical assistance opportunities designed to support the field as they continue to respond to patient and community needs. Resources are available in our Knowledge and Resource Center.

PRAPARE team launches its inaugural “Building Cross-Sector Partnerships to Address SDOH: Design Sprints” to unearth and rapidly test innovative solutions related to SDOH needs in local communities across the United States.

The PRAPARE team launched prapare.org to enhance learning opportunities for, and engagement with, PRAPARE users, their community partners, and their stakeholders. With a robust knowledge and resource center, a library of real-world examples, and a plethora of opportunities to connect with the PRAPARE team and fellow users, prapare.org will enable health centers, community-based organizations, and others to address SDOH more effectively and work upstream to improve health equity.