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  • 1.  SDOH

    Posted 03-01-2025 07:49

    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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  • 2.  RE: SDOH

    Posted 03-03-2025 11:20
    Edited by Becky Bishop 03-03-2025 11:21

    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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    Original Message


  • 3.  RE: SDOH

    Posted 03-04-2025 12:00
      |   view attached

    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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    Attachment(s)

    docx
    Final 2.24.25 (002).docx   32 KB 1 version
    Original Message


  • 4.  RE: SDOH

    Posted 03-05-2025 09:25
      |   view attached

    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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    Attachment(s)

    pdf
    CMS_2023_OMH_Z_Code_Resource.pdf   263 KB 1 version
    Original Message


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