Background/Purpose: Social determinants of health (SDoH) contribute significantly to disparities in care but are rarely addressed in subspecialty settings. The PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) tool is a validated questionnaire that screens for SDoH across multiple domains, including housing, employment, education, stress, and social support. Scores range from 0 to 22, with higher scores indicating greater social risk. At SUNY Downstate, the PRAPARE tool was implemented within a rheumatology and dermatology patient navigator program, which pairs 22 second-year medical students with 169 high-risk patients, yielding a navigator-to-patient ratio of 1:7.68. Since 2020, patients were recruited from subspecialty clinics based on identified needs such as severe disease manifestations, poor adherence to appointments or medications, and/or language barriers. Patients were randomly assigned to navigators unless a specific language preference was stated. Most participants were publicly insured (72%) and identified as Black or Caribbean (86.6%). The mean age was 48.5 years (SD 18.8), with a male-to-female ratio of 1:5.13. The most common conditions were lupus (53.6%) and hidradenitis suppurativa (52.0%).

Methods: Since program inception, 716 navigator-patient encounters were documented (mean 5.44 per patient; median 4.00), primarily addressing appointment scheduling (40.3%). To assess social risk, 64 of 169 patients (37.9%) completed PRAPARE screening via standardized telephone interviews conducted by navigators in December 2024.

Results: Among 64 individuals enrolled in a rheumatology patient navigator program, the mean PRAPARE social risk score was 5.9 (SD 3.32; range 1–18). The most frequently reported social needs were elevated stress levels (28%), housing instability (18%), limited social integration (16%), safety concerns at home (11%), and material insecurity (8%). Among the 9 patients with scores >8 (defined as a high social risk), 100% reported transportation barriers, 67% reported stress, and 56% reported housing instability. Subgroup analysis revealed that individuals identifying as Hispanic/Latino (p = 0.0204) and those with limited English proficiency (p = 0.0012) were more likely to have high PRAPARE scores. Spearman correlation analysis demonstrated a strong positive correlation between household size and total PRAPARE score (ρ = 0.72), suggesting that larger households may be associated with increased social risk burden.

Conclusion: The program identified a significant burden of unmet social needs among patients. These findings support the integration of routine SDoH screening in rheumatology clinics to better identify at-risk individuals and guide tailored interventions. Further research is needed to evaluate the long-term impact of targeted support measures on health outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/assessing-social-determinants-of-health-using-prapare-in-a-rheumatology-patient-navigator-program-for-underserved-brooklyn-communities/