(Research Hub Theater) Preparing for PRAPARE: Improving Social Risk Screening for Vulnerable Patients at a Federally Qualified Health Center

Background and/or Objectives: Individuals with disabilities are subjected to poorer health outcomes from unmet Social Determinants of Health (SDoH) needs. Physiatrists require social risk screening tools to comprehensively address patient physical functioning needs. The Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE) is a validated tool, including highly relevant SDoH risk assessments for physiatrists (e.g. housing stability, employment/insurance status, transportation, and mental health). We examined how to implement PRAPARE and identify at-risk patients in a Federally Qualified Health Center (FQHC) through quality improvement (QI).

Design: Plan, Do, Study, Act improvement cycle in a required longitudinal medical student service-learning course, informed by community assets and linked to quality-of-care needs.

Setting: Ambulatory-based FQHC in the San Fernando Valley of California with a patient demographic of mostly Hispanic patients (78%), 54% on Medicaid, and 40% uninsured.

Participants: FQHC clinic stakeholders (leadership, clinical staff, and contracted care coordinators).

Interventions: Over a one-year PDSA cycle, root causes identified included: social screening hindering clinical productivity, increased administrative workload, language barriers, electronic health record integration, ability to act on identified needs, and appropriate population for pilot implementation.

Main Outcome Measures: Identification of stakeholder priorities to implement PRAPARE and identification of patient's SDoH to screen for measuring quality-of-care targets.

Results: Adopting social risk assessments with minimized administrative burden were identified as priorities. 276 FQHC patients to screen were identified in an existing contracted care management program that managed hypertension, asthma, arthritis, and diabetes. Patients were > age of 65 with two or more chronic medical conditions. Contractors were recommended as having the capacity to screen, document, and refer patients to community resources to respond to identified SDoH needs.

Conclusions: Engaging with stakeholders through community asset-based QI enabled an optimal approach to address SDoH needs in a community-based setting. Physiatry practices in resource-constrained settings should consider utilizing similar systems-based approaches to evaluate optimal implementation of standardized SDoH screening.