Working with Blue Shield of California to Create a Comprehensive Picture of Community Health
During the summer of 2020, the California Primary Care Association (CPCA), in partnership with Blue Shield of California (BSC), supported the Regional Associations of California (RAC) and community health centers through learning cohorts to: (1) develop rapid community health needs assessment using the My Neighborhood Dashboard (NHD) digital intelligence tool, and (2) explore potential strategies to leverage aggregated Social Determinants of Health (SDOH) data from the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) assessment tool.
The PRAPARE Learning Cohorts are made up of CPCA members and BSC stakeholders in target counties divided into four regions:
Southern California: Counties of Los Angeles, Orange, and San Diego
Greater Sacramento: Counties of Butte, El Dorado, Placer, Sacramento, Sutter, Yuba, and Yolo
Inland Empire: Counties of Riverside and San Bernardino
Bay Area Coastal: Counties of Monterey and Ventura
The PRAPARE Learning Cohorts follow a nationally established training program with a three-pronged approach to SDOH. The first element is working with clinics and other stakeholders to understand what and how to use PRAPAPRE to collect data. The second is teaching clinics how to analyze and use the data they have collected through PRAPARE. The third element involves working with participants to understand how to develop either clinic resources or community partnerships to address the social needs identified through the data collected via the PRAPARE assessment. The virtual training sessions also include an overview of SDOH, integration of social needs into health care delivery, and Community Health Center (CHC) and other Medi-Cal provider requirements.
The NHD is a statewide Community Health Needs Assessment (CHNA) dashboard to better understand community-wide, social, economic, and physical conditions as well as social risk factors, health behaviors, and health outcomes for any California zip code. The NHD generator is accessible free to the public to elevate community health across the entire state of California. On March 2nd, CPCA hosted a workshop on connecting the NHD to SDOH screening.
In partnership with BSC and mySidewalk, CPCA is facilitating robust discussions about using the NHD that address the extent of health issues, their prevalence, severity, and the ability to evaluate outcomes on issues such as:
Impact on the whole population including trends, root cause of other health problems, social/economic cost, percentage of population at risk and barriers to intervention.
Ability to work on this issue covering topics such as Evidence-Based Interventions (EBIs) current availability, alignment with mission and values, capacity to address issues, opportunity to intervene at the prevention level.
Identified health issues’ disproportionate impact on certain populations which are at a higher risk, vulnerable, and experiencing persistent disparities, and discuss opportunities for partnerships with other groups.
Based on participant feedback, implementation of both the NHD and PRAPARE screening is evaluated for effectiveness, utility, and user experience to identify, prioritize, and align on community health needs. CPCA will engage stakeholders on all aspects of understanding the importance of assessing for unmet social needs and strategizing the implementation process of PRAPARE.
Finally, CPCA engages their own staff and networks on the importance of SDOH and the tools that were helpful to health centers for understanding unmet social needs and interventions.