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The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. As providers are increasingly held accountable for reaching population health goals while reducing costs, it is important that they have tools and strategies to identify the upstream socioeconomic drivers of poor outcomes and higher costs. With data on the social determinants of health, health centers and other providers can define and document the increased complexity of their patients, transform care with integrated services and community partnerships to meet the needs of their patients, advocate for change in their communities, and demonstrate the value they bring to patients, communities, and payers.


The PRAPARE assessment tool consists of a set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS). PRAPARE emphasizes measures that are actionable. PRAPARE Electronic Health Record templates exist for eClinicalWorks, Epic, GE Centricity, and NextGen and will be freely available to the public in late August 2016.

While not mandatory, it is important that users of PRAPARE collect standardized data on ALL of the core measures of PRAPARE.  Standardized data at the organizational, state, and national levels will accelerate population health planning, facilitate benchmarking across organizations, and document patient complexity that can inform payment models and risk adjustment.

PRAPARE Core Measures
Race Education
Ethnicity Employment
Migrant and/or Seasonal Farm Work Insurance
Veteran Status Income
Language Material Security
Housing Status  Transportation
Housing Stability  Social Integration and Support
Address/Neighborhood  Stress
PRAPARE Optional Measures
Incarceration History Safety
Refugee Status Domestic Violence


The PRAPARE Implementation and Action Toolkit

The PRAPARE Implementation and Action Toolkit is now freely available online and contains resources, best practices, and lessons learned to help guide interested users in each step of the implementation process, ranging from implementation strategies and workflow diagrams to Electronic Health Record templates and sample reports to examples of interventions to address the social determinants of health.


FAQs, Webinars, and Other Resources

  • Have more questions? Read through our Frequently Asked Questions.
  • Want a general overview of PRAPARE, how it was created, and what we’ve learned? Sign in to MyNACHC and search for “PRAPARE” to view our “Collecting Social Determinants Data with PRAPARE” webinar.
  • Want more in-depth information on how PRAPARE has been used on-the-ground and the technical specifications for the four Electronic Health Record PRAPARE templates (available for eClinicalWorks, Epic, GE Centricity, and NextGen)? Sign in to MyNACHC and search for “PRAPARE” to view our Electronic Health Record-specific webinars.


PRAPARE has been a multi-year effort between NACHC, the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures, along with a group of pioneer health centers and health center networks in Hawaii, Iowa, New York, and Oregon. PRAPARE was supported with funding from the Kresge Foundation, the Blue Shield of California Foundation, and the Kaiser Permanente National Community Benefit Fund at the Easy Bay Community Foundation.

© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association.  PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients.  Do not publish, copy, or distribute this information in part or whole without written consent from NACHC.

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