Open Forum

We just implemented the social determinants of health and are using the Prepare questions. Does anyone have a policy they can share with me? In addition, how do you follow up with the patient? Like many of the prior post our patients are filling out on there own and we review later and call the patient with resources,  looking how other clinics are managing. We are a small rural clinic 

Thank you 

Donna OGrady RN BSN 

Clinical Manager 

1423 Stone St 

Falls City NE 68355

dogrady@fcfpc.org

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Donna O'Grady
Falls City NE
(402) 650-9456
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We don't have a policy however our workflow has these questions in writing, and they receive them at check in. (full disclosure we do not use the PRAPARE questionnaire specifically) Generally, they are complete by the time we bring them back to room them. Then we can discuss any "positive" findings, provide resources immediately and eliminate the need to circle back. Nursing staff inputs the answers into Epic either during rooming or while the provider is seeing the patient. 

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Becky Bishop BSN RN
Monument Health
Belle Fourche SD
(605) 939-9868
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Good morning, 

We just began our workflow yesterday, so I can't speak to how well it is working quite yet.  However, I am happy to share it. Please see attached. 

Angela

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Angela Hall MN RN
Neighborhood Health Center
Oregon City OR
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Original Message:
Sent: 03-03-2025 11:20
From: Becky Bishop
Subject: SDOH

We don't have a policy however our workflow has these questions in writing, and they receive them at check in. (full disclosure we do not use the PRAPARE questionnaire specifically) Generally, they are complete by the time we bring them back to room them. Then we can discuss any "positive" findings, provide resources immediately and eliminate the need to circle back. Nursing staff inputs the answers into Epic either during rooming or while the provider is seeing the patient. 

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Becky Bishop BSN RN
Monument Health
Belle Fourche SD
(605) 939-9868
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This is so timely. Thank you for the work you all are doing to identify and work to meet the HRSNs patients have.

One thing to consider incorporating into this workflow is to code positive findings using Z-codes so that data is captured and can be used at a population level. These are not billable codes, but do work to tell the patient's story to payers, reflect the complexity of the patient, the challenges faced by them and the clinicians caring for them. Important in value-based care contracts and programs! CMS has some good resources on this topic (see attached infographic), as does the AAFP: https://www.aafp.org/pubs/fpm/issues/2022/0300/p6.html.

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Leslie McDowell ANP-BC DNP RN
Northwest AHEC/Wake Forest Univ Sch of Med
Winston Salem NC
(336) 972-7852
ANP-BC DNP RN
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