Partnering with community-based organizations to address social determinants of health

Last month, the Kentuckiana Health Collaborative sponsored a two-part webinar discussing ways that community-based organizations can partner to address social determinants of health (SDOH).

Part one focused on recognizing the impact of SDOH, reviewing considerations to launching an initiative to address SDOH and exploring case studies of partnerships between healthcare and community-based organizations.

Part two focused on the innovative approaches that multiple organizations in our community are taking to improve SDOH, particularly in the area of food and housing insecurities.

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH have an impact on health outcomes.

Health coverage alone is not enough to improve health outcomes. For example, physicians may encourage healthy eating, but may not realize how difficult that can be for some patients (i.e. not easy to get to a grocery store, may not be able to afford groceries over the whole month).



Cynthia Cox, the director of Health Information Management at Family Health Centers in Louisville, Kentucky discussed the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) pilot, created by the National Association of Community Health Centers (NACHC).

PRAPARE is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health.

In January 2018, Family Health Centers began working with the Louisville Health Advisory Board to pilot the PRAPARE tool. Use of the tool was launched in July 2018 with a small pilot group where medical assistants administered the questionnaire.

By October 2018 they expanded to a second site and included a hypertension program, lead by the health education department. Patients were screened by conversation rather than by questionnaire. A community health worker was connected if the patient had more than three needs.

In early 2019, the program expanded to seven of eight sites. The integrated behavioral health department now has clinical social workers completing the forms when a need is identified.

In June 2019 Family Health Centers launched a “no wrong door” approach to refer patients to United Community license holders. Staff can make referrals either in the electronic health records or on the Family Health Centers’ intranet site. United Community is a community-wide initiative to deploy an innovative shared technology platform to initiate and close referrals across many organizations.

The data coming out of using the PRAPARE tool is useful. According to Cox, assessing needs is not enough. Cox explained, “Community partnerships are an important part of this project. The community must come together and wrap around the individual and address the needs. Once we do that, we will  have a meaningful impact on an individual’s quality of life and health outcomes.”

The Louisville Health Advisory Board is working to expand the use to other clinics throughout the community, including: Home of the Innocents, Family Community Clinic, Shawnee Christian Health, Park Duvalle and Smoketown Family Wellness Center.


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