This project tested the impact of an industry standard social determinants of health (SDOH) screening tool, Protocol for Responding to and Assessing Patient’s Assets, Risks and Experiences (PRAPARE)[1], on connecting SDOH resources with high-risk Medicare Advantage (MA) members to improve access, enhance quality, and reduce unnecessary healthcare expenditures.

Research shows unmet SDOH needs drive as much as 80% of health outcomes and result in increased utilization of emergency department (ED) visits and hospitalizations[2],[3]. Adoption of a standardized method to screen for and connect patients to SDOH resources can enhance outcomes and drive medical savings.

An educational program, document repository, quick reference guide, and project playbook were created. Staff in three primary care clinics adopted a uniform method of assessing patients using PRAPARE. Patients who screened positive for SDOH needs were matched with social support services through internal assets, community resources, or FindHelp.org[4]. At the completion of eight weeks, data was analyzed.

There were 270 eligible patients; 226 were screened and 64 (28%) patients were found to have at least one SDOH need. 94 of those who screened positive were immediately connected to SDOH resources by the clinic staff, and 6% were referred to social workers (SW) for enhanced assistance. Social work referrals increased from an average of seven to 19 referrals per month as did z-code documentation adherence in comparison to past performance.

The impact on ED utilization and inpatient admissions are in early phases of data collection, with plans to scale this streamlined and effective approach to additional primary care clinics already initiated. By implementing standardized screening tools and intervention methodologies, we can impact patient health outcomes, proactively address the upcoming social needs screening and intervention (SNS-E) quality measures and health equity index (HEI) financial ratings, thus advancing the quadruple aim.

[1] The PRAPARE Screening Tool - PRAPARE
[2] Medicaid’s Role in Addressing Social Determinants of Health. (n.d.). RWJF. https://www.rwjf.org/en/insights/our-research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html
[3] Beaton, T. HealthPayerIntelligence. (2018, March 28). Payers Form Coalition to Address Social Determinants of Health. https://healthpayerintelligence.com/news/payers-form-coalition-to-address-social-determinants-of-health
[4] findhelp.org by findhelp - Search and Connect to Social Care

Carolyn Monroe MS, RN, APN-C, AHN-C

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