Abstract
Purpose: This quality improvement project embedded the social determinants of health (SDOH) PRAPARE screening tool (NACHC, 2019a) questions into the clinic’s patient demographic form, utilized the information to inform holistic patient care, and built the clinic’s community resource inventory and referral process. The three-phase project provided implementation training, evaluated the implementation process via feedback surveys during the project launch period, and concluded with a report to the clinic board of initial findings from aggregate patient demographic form data and implementation process.|Background: This project has application for primary care, public health, and clinical administration. SDOH factors significantly contribute to chronic illness must be addressed by the healthcare system, particularly in the primary care arena to decrease chronic disease burden and healthcare costs.|Sample/ Setting: The sample included all patients (N = 330) seen for 10 clinic nights in October, 2019. The free clinic is located in a mid-sized city in the midwestern United States.|Methods: The project utilized the Advancing Research and Clinical Practice through Close Collaboration (ARCC) model, the Five Rights of Clinical Decision Support framework, and the Plan Do Study Act (PDSA) cycle. Descriptive data analysis was utilized for both patient and process evaluation.|Results: Of the 330 patients, all patients were given the updated patient demographic form with the embedded PRAPARE tool questions. There were 599 resource sheets given. The top four areas of need identified were: (1) healthcare insurance, (2) employment, (3) mental health, and (4) housing. The project process feedback survey general response was positive.|Conclusion: This project improved identification of SDOH factors, helped inform clinician care provision, and increased referrals and resources provided to patients. Further research could be done to track utilization of resources and health outcomes. While this project data is specific to one free clinic, the aims can be replicated utilizing this action-oriented process in other safety net clinics to address SDOH.|Key words: Social determinants, PRAPARE tool, free clinic, holistic patient care, community resources, PDSA model, five rights of CDS framework, ARCC model, screening, Secondary prevention, primary care, underserved