Emerging alternative payment models (APMs) and accountable care organization (ACO) models increasingly require accurate social determinant of health (SDH) and community resource information. Infrastructure and processes are required to collect and aggregate patient and community-level SDH data, and efficiently utilize it to connect patients to the right community services, evaluate risk, transform care, and maximize new payment models. In OCHIN's network, health centers have been using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) tool developed by NACHC, the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures to collect and respond to SDH data. Presenters will share lessons learned on aggregating data across OCHIN's member health centers and analyzing that data to inform care transformation and APMs.
- 1) Review the need for and opportunity to use patient and community-level SDH to maximize APM programs.
- Understand how PRAPARE data findings from OCHIN research projects can inform risk evaluations.
- Understand how SDH data, resulting from PRAPARE, can be used to transform patient care.