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**CONTENTS**
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[[_TOC_]]
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#### Background
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PHACO Program Aims to Address Modifiable Social, Economic, and environmental Factors in Primary care
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* _WHAT_: Launched in March 2018, a 13-question screener was developed with input from SDOH subject matter exports, with the goal of addressing modifiable risk factors and improving quality of care for Medicaid patients presenting to Partners' primary care sites. The screener focuses on the following domains:
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* Employment
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* Education
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* Care of a family member
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* Food
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* Transportation
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* Paying for Utilities
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* Housing
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* Intimate Partner Violence
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* Paying for Medications
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* _WHERE_: All Partners adult and pediatric primary care sites
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* _WHEN_: Screener is assigned to all New Patient, Annual Physical, and Non-Urgent Follow-Up primary care visits
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* _WHO_: Medicaid patients, as the program is primarily funded through Medicaid Delivery System Reform Incentive Payments (DSRIP)
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* _WHY_: The SDOH screener helps to identify patients with health-related social needs and connect with appropriate community-based resources. We are hopeful that the SDOH screener will help our primary care practices to better address patients' unmet health needs and perform well on Medicaid ACO quality measures.
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#### SDOH Program Reporting Overview
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+ Data being captured in the Medicaid ACO SDOH Program Dashboard are refreshed weekly (typically Monday or Tuesday) directly from the PHS Enterprise Data Warehouse (EDW): See date/time stamp on dashboard.
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