What is Health Equity?

The Robert Wood Johnson Foundation offers a definition: “Health equity means that everyone has a fair and just opportunity to be as health as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

https://www.cdc.gov/chronicdisease/healthequity/index.htm

https://www.apha.org/topics-and-issues/health-equity

What are Social Determinants of Health and Enabling Services?

Mahalo to our health center partners for your valuable feedback throughout the development of the videos, and to Lee-Ann Heely, Director of Innovation and Transformation at West Hawai‘i Community Health Center, for lending your voice to this project.

For more information on how to start collecting SDOH data, visit the PRAPARE website here: PRAPARE

For more information on how to start collecting Care Enabling Services data, visit the following link: CARE ENABLING

AAPCHO Enabling Services Webinar SerieS 2021 (password required)

identifying social needs

SCREENING TOOLS

There are a number of SDOH Screening Tools available. For a comprehensive listing, please visit, the SIREN website for their Social Needs Screening Tool Comparison Table.

Here are the most common screening tools utilized by our health centers. 

PRAPARE Action Toolkit: https://www.nachc.org/research-and-data/prapare/toolkit/  

Accountable Health Care Communities Health-Related Social Needs Screening: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf  

Health Leads Screening Toolkit: https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/  

IMPLEMENTATION RESOURCES

Oregon Primary Care Association SDOH Crosswalk 

SDOH Workflows developed by Oregon Primary Care Association 

• Non-clinical staff before the office visit: https://www.orpca.org/files/OPCA SDH non-clinical-staff-before-visit.pdf  

• Non-clinical staff during the office visit: https://www.orpca.org/files/OPCA SDH non-clinical-staff-during-clinical-visit.pdf  

• Non-clinical staff after the office visit: https://www.orpca.org/files/OPCA SDH non-clinic-staff-after-visit.pdf  

• Workflow builder: https://www.orpca.org/files/OPCA%20Workflow%20Builder_May%202019.xlsx 

COMMUNICATING ABOUT SDOH

Lone Star Circle of Care in Texas offers an email message that would be helpful if you are considering launching your SDOH screening by email or through your patient portal. http://www.nachc.org/wp-content/uploads/2019/01/Lone-Star-Email-Messaging.pdf  

Venice Clinic in California offers a script for staff to introduce the screener to patients. 

http://www.nachc.org/wp-content/uploads/2019/01/PRAPARE-script-Venice-Family-Clinic.docx 

Oregon Primary Care Association developed a conversation guide to help walk you through the questions with patients. 

https://www.orpca.org/files/11 Empathic Inquiry Conversation Guide.pdf 

Responding to identified social needs

• Aloha United Way (2-1-1)  - https://www.auw211.org/s/  

• Findhelp.org  - https://www.findhelp.org/ 

• Unite Hawai‘i - https://hawaii.uniteus.com/  

Care Enabling Services Toolkit 

Care Enabling Services Data Collection Implementation Packet: https://aapcho.org/enabling-services-data-collection-implementation-packet/