In today’s value-based care environment, organizations are accountable for improving health outcomes and lowering costs. To achieve these goals and succeed in such an environment, organizations need to better understand their patients to address both their clinical and non-clinical needs and impact the root causes of health, including patients’ health behaviors, health outcomes, and health costs. The social determinants of health (SDH) are the conditions in which people live, work, play, and age. They can encompass socioeconomic conditions, environmental conditions, institutional power, and social networks. Understanding patients’ social determinants will allow health centers to transform care with integrated services to meet the needs of their patients, address the social determinants of health, and demonstrate the value they bring to patients, communities, and payers.
There are 433 Health Center Programs located in or immediately accessible to public housing, serving close to 5.2 million patients. Of those, 108 receive Public Housing Primary Care (PHPC) grants and serve approximately 856,191 patients. Public housing means agency-developed, owned, or assisted low-income housing, including mixed-finance projects, but excludes housing units with no public housing agency support other than section 8 housing vouchers.
Characteristics Of Public Housing Primary Care (PHPC) Health Center Patients:
- 28.29% of patients are less than 18 years old.
- 62.22% of patients are adults (18-64)
- 8.96% of patients are older adults (65 and older)
- 20.43% of patients are uninsured
- 53.76% of patients receive Medicaid
- 9.01% of patients receive Medicare
- 4.64% of patients are dual-eligible (Medicaid and Medicare)
- 77.57% of patients are at or below 100% of Federal Poverty
Source: Source: HRSA, 2019 Health Center Program Data
WHAT IS PRAPARE?
The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers collect and apply the data they need to better understand their patients’ social determinants of health. PRAPARE is both a standardized patient social risk assessment tool consisting of a set of national core measures as well as a process for addressing social determinants at both the patient and population levels. By using PRAPARE, providers can better target clinical and non-clinical care (often in partnership with other community-based organizations) to drive care transformation, delivery system integration, as well as improved health and cost reductions.