Why it Matters

The Social Determinants of Health (SDH) are the conditions in which people are born, live, work and age. They are shaped by the distribution of money, power and resources at global, national and local levels. SDH account for an estimated 60 percent or more of health outcomes and are largely responsible for health inequities. Social factors influence both an individual’s physical environment and health behaviors. To achieve health equity, where everyone has a fair and just opportunity to be as healthy as possible, it is essential to address the social determinants of health.

SDH graphic 4 SDH graphic 3

Community health centers provide numerous services which address the social determinants of health including transportation, housing support, peer support groups, and food programs. Screening for social needs is a powerful mechanism to identify individual patient needs and provide support and services to address these concerns. Additionally, screening helps community health centers develop targeted interventions, improve care coordination and patient engagement, and make better use of partner/enabling services.

Social needs are shaped by the broader social factors – or determinants – in people’s lives. Beyond screening for needs, CHCs also serve as advocates to shape policy and structures that perpetuate health inequities. By moving upstream, CHCs serve as a catalyst to disrupt this cycle and prevent disease and poor health outcomes.

OPCA's Health Equity & Social Care Work


Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

OPCA partners with the National Association of Community Health Centers (NACHC) and Association for Asian and Pacific Community Health Organization (AAPCHO), to develop and roll out a standardized social needs screening tool for community health centers nationwide. PRAPARE is both a protocol and a tool to help care teams collect the data needed to better understand and respond to patient’s social needs, and is the dominant social needs tool used in health centers today.

OPCA supports and consults on national research projects with key partners including the following:

  • CMS Accountable Health Communities (Oregon pilot) – a five year study focused on learning whether systematically finding and supporting the health-related social needs of Medicare and Medicaid beneficiaries has any effect on their total health care costs and outcomes (2017–2022).
  • OCHIN’s ASCEND Project –a five-year study aimed at understanding whether or not structured technical assistance improves uptake of social needs screening efforts in health centers (2017– 2022).
  • Social Interventions Research & Evaluation Network (SIREN) – a qualitative study to learn more about how Medicaid dollars are used to support social needs efforts in clinical settings. Read Health Affairs paper out in May 2019 here.


Advancing Health Equity and Data (AHEAD) Collaborative

AHEAD is an OPCA two-track learning collaborative which focuses on supporting Oregon health centers in collecting and utilizing social determinants of health data to demonstrate value, will highlight best practices in health centers both locally and nationally, and will consist of face-to-face, webinar, and peer-learning opportunities.

Advanced Payment and Advanced Care Model (APCM)

In partnership with the Oregon Health Authority, OPCA’s APCM program increases flexibility for community health centers to focus on developing a more effective approach to improving population health. APCM allows health centers to understand and respond to the non-medical circumstances that influence their patients’ needs and priorities, which may be best addressed outside the examination room and even outside the walls of the clinic.

Empathic Inquiry

OPCA developed a curriculum called Empathic Inquiry, a conversational approach to social needs screening to promote partnership, affirmation and patient engagement through social needs screening.


Policy & Advocacy involvement

OPCA collaborates with Oregon health centers, partners, and policy makers to shape public policy to achieve health equity for all Oregonians.

Oregon Health Authority Health Equity Committee

OPCA participates in the health equity committee to influence and support Oregon efforts in coordinating and developing policies that proactively promote the elimination of health disparities and the achievement of health equity for all people in Oregon.

For more information about OPCA's health equity and social care work, contact:
Courtney Kenney,   


Oregon Health Centers' Health Equity Work

Oregon Case Studies, Articles, and Presentations

Oregon Community Health Center Reports