DC PACT (Positive Accountable Community Transformation)

DC PACT is hosting a Strategy Retreat to launch us into 2018 focused on advancing our collective impact agenda to build a health network that consistently identifies and addresses the social determinants of health! The session will define our coalition principles and establish and hone our goals and boundaries. Interested in playing a part in setting DC PACT’s course in the year ahead and beyond? Contact David Poms dpoms@dcpca.org for more info, and learn more about PACT here: http://www.dcpca.org/dc-pact


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

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.

Vision and Mission

Vision: DC functions as a seamless accountable health community that
addresses unmet social needs to improve health and increase equity

Mission: Build the movement to reframe the culture of care delivery to address
social needs, improve health outcomes, and increase health equity in the
District of Columbia

Strategic Goals: By December 2020…

• Standardize social needs screening citywide and establish DC PACT
expertise on analysis, reporting, and dissemination of social needs/health
outcomes data

• Position DC PACT as a clearinghouse and hub for health system action to
address social needs and improve health equity

• Leverage a bidirectional cloud-based health information exchange to
identify the social needs of patients, facilitate high quality care
coordination, and enable staff to provide effective referrals that can be
tracked in a standardized process

• Standardize shared measurement assessment among DC PACT members
for the purposes of reporting, analysis, and dissemination of population social health data

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. 


Our Members

AmeriGroup DC
AmeriHealth Caritas DC
Bread for the City
Capital Area Food Bank
Capitol Hill Group Ministry
CareMore Health
Children’s National Medical System
Children’s Law Center
Community Connections
Community of Hope
DC Behavioral Health Association
DC Greens
DC Hospital Association
DC Primary Care Association
Family & Medical Counseling Services
Food & Friends
George Washington Hospital
Health Services for Children with Special Needs
Hillcrest Children & Family Center
Howard University Hospital
Institute for Public Health Innovation
La Clínica del Pueblo
Leadership Council for Healthy Communities
Mary's Center
MedStar Hospitals
Providence Health System
Regional Primary Care Association
So Others Might Eat
Trusted Health Plan
Unity Health
Vitas HealthCare
Whitman Walker Health

Government Partners:

DC Health
Department of Behavioral Health
Department of Disability Services
Department of Energy & the Environment
Department of Health Care Finance
Department of Human Services
Interagency Council on Homelessness
Fire and Emergency Management Services

2019 Action Team Objectives 

CoRIE Action Team

1) Engage social health sector on standardized screening and data sharing; promote citywide

2) Assess stakeholder priorities and technical requirements for citywide data sharing system

3) Develop resource inventory of community support programs and organizations

Shared Measures Action Team 

1) Develop an approach to create shared measures at coalition, community, and individual level

2) Begin planning for how DC PACT will take action on shared measures

Upstream Action Team

1) Begin development of DC PACT upstream work through participatory asset mapping

2) Map out opportunities for shifting health care to social spending and develop DC PACT action strategy


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