Applying PRAPARE Social Determinants of Health Data for Practice Transformation and Risk Stratification

Identifying the socioeconomic and structural drivers of poor outcomes and higher costs is increasingly important when caring for complex patients. By collecting standardized data on the social determinants of health, using the PRAPARE tool, health centers can better understand the complexity of their patient populations and use that information to inform care delivery and population health management. This session will cover key strategies health centers and PCAs used to begin PRAPARE implementation and integrate social determinants data collection into practice and how they progressed to incorporating PRAPARE data into care planning. Presenters will highlight different methods for incorporating PRAPARE data into risk stratification models to segment populations, provide more appropriate care, better allocate limited resources, target interdisciplinary teams, and provide needed social services—either in-house or through community partnerships.