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Doctor and Patient
Clinical Corner – PRAPARE
Protocol for Responding to Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

According to the Centers for Disease Control and Prevention, Social Determinants of Health (SDOH) are conditions present in the localities, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes. To effectively manage the health and wellness of a patient population, it is important to look outside of the practice walls.


PRAPARE is a standardized patient social risk assessment tool made up of a set of national core measures with a set of optional measures for community priorities. PRAPARE is one of CMS' approved tools to screen patients seen by the practice during the performance years for the presence of SDOH. The form is one of the three CMS-certified options to report on SDOH data collection for 2024. The tool aligns with the national Social Determinants of Health (SDOH) initiative, measures proposed under meaningful use (EHR standards), ICD-10 clinical coding, and health centers' Uniform Data System (UDS). The core PRAPARE measures are:


  • Address/Neighborhood

  • Education

  • Employment

  • Ethnicity

  • Housing Stability

  • Housing Status

  • Income           

  • Insurance

  • Language

  • Material Security

  • Migrant and or Social Farm Work

  • Race

  • Social Integration and Support

  • Stress

  • Transportation

  • Veteran Status


The optional PRAPARE measures are:


  • Domestic Violence

  • Incarceration History

  • Refugee Status

  • Safety


Social Determinants of Health are crucial drivers of health outcomes and inequities in the United States and account for approximately 80% of health outcomes, compared with only 20% for health care. SDOH screening tools will help providers quickly and efficiently screen their patient base and offer insight into social factors that may be impacting health outcomes.


It is important for physicians to assess social needs and connect patients with appropriate resources. PRAPARE helps guide healthcare providers who serve underserved populations toward more integrated care. PRAPARE templates may already be in the Electronic Health Records (EHR) such as eClinical Works, Epic, GE Centricity, and NexGen and are free to the public. Gathering SDOH information is a CMS requirement for 2024 for the ACO Reach. The PRAPARE will help you link the appropriate Z Codes based on the patient’s responses to each PRAPARE question.

For our aligned physicians, please reach out to your EHR representatives to add appropriate information – they will be happy to help!

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