Woman with nurse

The unique community-based and integrated care model at Spectra Health in Grand Forks, ND, allows the care team to address behavioral, oral, and medical health as well as assistance with transportation and housing needs. The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)  tool allows Spectra Health staff to get to the root of an individual’s need at both the clinic and community level.

Casey B Spectra HealthCasey Berberich, LMSW, a behavioral health consultant at Spectra Health, shared her experience using PRAPARE. “We found that individuals were not discussing issues that impacted their overall well-being in their early appointments. Now, having the answers to these important questions, the team at Spectra Health can connect individuals with community services and resources sooner than we could before.”

The PRAPARE tool is a national effort to help health centers and other providers collect and apply the data they need to better understand their patients’ social determinants of health, transform care to meet the needs of their patients and ultimately improve health and reduce costs. Integrated into the electronic health record or available for print, the PRAPARE form asks questions related to personal characteristics, family and home, money and resources, social and emotional health as well as other key issues, including domestic safety, violence and incarceration history.

Berberich added, “The PRAPARE tool offers me confidence, as a provider, rooted in the fact that I can provide a resource to assist, whether it be an insurance issue, safety in the home or food insecurities.”

The Spectra team has had access to the PRAPARE form for nearly a year, but made a concerted effort to utilize the tool in mid-June 2021. Staff were offered training and referrals were put into place. As a result, the quality of responses has improved dramatically and the turn-around with deployment of identified services and resources has improved as well.

“The PRAPARE tool provides a structured way to identify the topics most likely to impact a person’s ability to engage in the care process. We utilize the tool for ‘newly-established’ individuals who are establishing medical care at our facility. The PRAPARE tool allows us to go through each item, in a systemic format, and address areas that will hopefully allow us to improve the care we offer. It also helps the patients achieve better health outcomes,” stated Berberich.

PRAPARE has been a multi-year effort between the National Association of Community Health Centers, the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures.

“The thing I love most about it is being right there to make sure we are available to our patients to make things happen. The tool is amazing and helps build trust and offer quality care, which is extremely important,” concluded Breberich.

Diversity circle for PFEA Patient Story: A Housing Crisis Averted

Jen* had a primary care provider at another location, but utilizes Spectra Health for a medication refill. Jen visited the clinic regularly, but she was always a bit guarded. One day Jen’s boyfriend came in for a health-related issue. As a new patient, Breberich began to ask questions using the PRAPARE form. As a result, it became known the couple were facing a housing crisis. Berberich was able to direct to resources and help secure housing for Jen and her boyfriend. After, Jen was more friendly and transparent in her interactions with the Spectra Health team. She trusted them and was grateful for the assistance they offered. She indicated she was so happy to learn of the additional help and services she could access at Spectra Health.

*Jen is not the individual’s real name, but the scenario is of an actual patient. This scenario demonstrates the value and benefit of the PRAPARE tool utilization.