DC PACT (Positive Accountable Community Transformation)


In August and September coalition meetings, DC PACT made progress toward our vision of a seamless accountable health community that maximizes resources and collaboration between clinical and community supports and systematically identifies and addresses the social determinants of health.


Reflecting on several rounds of stakeholder input, PACT members selected three domains of social need to prioritize for screening – housing, income security, and mental health/substance abuse, which emerged as some of the highest priorities for our membership. In September, we considered screening measures already in use by PRAPARE (the social screening tool from NACHC), CMS, and other similar sources. In the coming months, we will work with the Department of Health Care Finance to finalize our preferred measures and identify how these measures can be standardized and incorporated into screening processes across our health system.


Standardizing these measures will be an important step for us to take as a coalition, as it will ensure that all members are collecting the same types of data, making them comparable across our network and useful for population health management within our city and research compared to similar initiatives elsewhere. Standardizing our measures will also create new value for our partners, supporters, and funders who are looking to DC PACT to lead the way in addressing the social determinants of health. As we move forward together toward standardization, we’ll be able to bring new resources to bear to support other elements of the PACT initiative and move our city toward greater health equity.


For more information on screening measures, see below:



Preliminary Measures (to be determined in conjunction with broad DHCF stakeholder process)

  1. What is your housing situation today?      
    1. I do not have housing
    2. I have housing today, but I am worried about losing housing in the future
      1. (follow up) I am:
        1. Staying with others 2. In a hotel 3. In a shelter 4. Living outside on the street 5. On a beach 6. In a car 7. In a park 8. Other
    3. I choose not to answer this question
  2. Think about the place you live. Do you have any problems with the following?
    1. Bug infestation b. mold c. lead paint or pipes d. inadequate heat e. oven or stove not working f. no or not working smoke detectors g. water leaks h. none of the above

[Source: Center for Medicaid and Medicare Innovation (CMMI) – Accountable Health Community (AHC) Pilot Standardized Screening Tool, and the PRAPARE tool from the National Association of Community Health Centers]


Narrative: The breakout group considered these two measures from the AHC tool, and the housing measure from PRAPARE, and decided that the AHC measures were more useful, due to the greater capacity of question 1.b to identify those with housing-related social needs, but who are not completely without housing. The group also recommended that the follow up to 1.b incorporate a list of specific transitional housing statuses, to help manage population health and research. The group also viewed question #2 favorably regarding the quality of a patient’s housing conditions, as things like mold, lead, and kitchen appliances are often related to patient health and self-efficacy.


Income Security

Preliminary Measures (to be determined in conjunction with broad DHCF stakeholder process)


  1. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?
    1. Food b. Utilities c. Medicine or any health care (medical, dental, mental health, vision) d. Phone e. Clothing f. Child Care g. Transportation h. other
  2. What is your current work situation?
    1. Unemployed/seeking work b. part time/temporary work c. Full time work d. otherwise unemployed but not seeking work (student, retired, disabled, unpaid primary care giver) e. other (write-in) f. choose not to answer



[Source: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) from the National Association of Community Health Centers (NACHC)]


Narrative: The DC PACT breakout group considering income security measures recommended inclusion of the first measure based on its ability to identify patients with income challenges in a number of categories, as well as the second measure which identifies patients with work challenges. The first question in particular was felt to be broad and flexible enough to capture most aspects of income security, eliminating the need to have redundant food and transportation security measures.


Mental Health/Substance Abuse

Preliminary Measures (to be determined in conjunction with broad DHCF stakeholder process)

  1. In the past year, how often have you used the following? (choose from never, once or twice, monthly, weekly, daily, or almost daily)
    1. Alcohol b. Tobacco products c. Prescription drugs for nonmedical reasons d. illegal drugs
  2. Have you ever felt you ought to cut down on your drinking or drug use?
  3. Over the past two weeks how often have you been bothered by:
    1. Little interest or pleasure in doing things?
    2. Feeling down, depressed or hopeless?

[Source: National Institute on Drug Abuse (NIDA) quick screening tool, and Clinical Integrated Network (CIN) working group on SDOH]


Narrative: The DC PACT breakout group felt that these measures would be useful for identifying patients who are at risk of substance abuse and depression, favoring question #1 in particular for its usefulness for a variety of health uses. They considered the frequency of screening, particular for #2 and #3, vital to their usefulness – the larger concern was about specific substance use, not as much about frequency. Some suggestions for edits on these questions include separating out marijuana as its own answer in #1, due to its nascent quasi-legality, as well as adding smoking to #2.  The group also discussed including further measures for this domain, including measures for anxiety, personal safety/domestic violence, and social connection. 


Who We Are

The DC PACT  (Positive Accountable Community Transformation) is a coalition effort of community providers, including social service non-profits, faith institutions, behavioral health providers, hospitals, and community health centers, in partnership with multiple District government agencies including the Department of Health Care Finance, Department of Human Services, Department of Behavioral Health, and Department of Disability Services. DC Primary Care Association serves as the Collective Impact “backbone” organization, guided by an Advisory Council.   DC PACT seeks to identify and address social challenges that create health disparities by linking safety net provider organizations in the District.

Our Goals

  1. Build a health network that consistently and systematically identifies and addresses the unmet social needs of patients;
  2. Maximize resources and collaboration between clinical delivery sites and community service providers to eliminate duplication and close gaps utilizing HIE;

Expand the capacity of all partners to function as a seamless accountable health community over time and across sites of care through increased cross-sector collaboration.

Our Work

DC PACT is working to test the theory that the District has much of what we need to thrive, if we align our resources around our community’s needs and strengths.

DC PACT seeks to build a health network that systematically and consistently identifies and addresses unmet social needs and expands the capacity of all partners to function as a seamless accountable health community over time and across sites of care.

DC PACT has adopted the collective impact framework to envision and undertake its work. The collective impact framework is a structure to address complex social challenges that require multi-sector alignment. In some successful collective impact initiatives, the changes in organizational behavior that result from intentional alignment toward a common agenda have impact even without significant new resources or innovations. DC PACT remains open to the emergent solutions that may spring from committing to shared goals. 


At the recent DHCF MAPing Summit (Measuring, Assessing, Planning the Use of Social Determinants of Health Data in the District), DC PACT was a lead partner in efforts to address social needs in the District’s Medicaid and Alliance programs. The many organizations throughout the health ecosystem already screening for or addressing social needs make evident the need for alignment of multiple initiatives.  The District must not miss the opportunity to link and hone the trickling streams of “mutually reinforcing activities” into a powerful river driving a system toward better outcomes for all.

Our Members

AmeriHealth Caritas

Bread for the City

Capital Area Food Bank

Capitol Hill Group Ministry

Children’s Law Center

Community Connections

Community of Hope

Covenant House

DC Greens

DC Primary Care Association

Family & Medical Counseling Services

Family Voices of DC

George Washington University Hospital

Health Services for Children with Special Needs

Hillcrest Children & Family Center

Howard University Hospital

Institute for Public Health Innovation

Interagency Council on Homelessness

La Clínica del Pueblo

Leadership Council for Healthy Communities

Mary's Center

MedStar Health


Network for Victim Recovery of DC

Providence Health System

Vitas HealthCare

Allied District Government Supporters


Government Partners:

DC Department of Behavioral Health

DC Department of Disability Services

DC Department of Energy and Environment

DC Department of Health

DC Department of Health Care Finance

DC Office of Aging


Community-Clinic Linkages Subcommittee

Goal: Facilitate outreach, development, and capacity building for partnerships between clinical and community organizations that meet the social needs of patients

Vision: Clinical and community organizations will understand how they can plug into the DC PACT network to find partners to address the social and clinical needs of their patients and participants. Through DC PACT, organizations will work to align resources and build capacity to address social needs, thereby increasing the efficiency of resource allocation in the District and improving the health status of residents. Success will mean creating a strategy for building the capacity of all DC PACT organizations to have the resources they need to meet the social needs of patients.

Fundraising Subcommittee

Goal: Position DC PACT to receive sustainable funding to implement  goals related to technology and community partnerships

Vision: Clinical and community organizations have the resources they need to address the social needs of their patients and participants. They will understand how they can partner with DC PACT to build their capacity to address social needs. Key funders and payers will understand how supporting DC PACT activities will result in improved health and social outcomes, including improved health status and allocative efficiency of health resources across the District, and reduced health disparities, and will work with DC PACT to shift policies and funding streams to support meeting the social needs of patients.

Technology Subcommittee

Goal: Develop technology solutions that can link community and clinical organizations for communication and coordination of services for patients with social needs

Vision: DC PACT supports creation of backbone technology solutions that enable organizations in the District providing community and clinical services to interface with a resource directory and referral system that communicates in real time between participating organizations. Success will mean that all relevant clinical and social service organizations are able to find and refer patients to the resources they need to improve their health status.


Does your organization want to join DC PACT?