Aggressively and systematically addressing the social determinants of health

How a health center in Sioux City, Iowa is using data and enabling services to improve the health of its community

Enabling Services Day Podcast – Q&A with Dave Faldmo | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting all of the enabling services health centers provide – services like transportation, interpretation, case management, housing assistance, and countless other programs and initiatives health centers have created in direct response to the unique needs they find in their community. Today we’re hearing from Dave Faldmo, quality director at Siouxland Community Health Center in Sioux City, Iowa. Dave will share with us how their center is using data to learn more about the needs of their patients and addressing those needs through enabling services.

DaveFaldmoQ&A with Dave Faldmo

Tell us a bit about yourself and your role at Siouxland Community Health Center.

I first started seeing patients a few hours a week at Siouxland Community Health Center (SCHC) not long after graduating from the University of Iowa’s PA program in 1992. Since then I’ve worked part-time as a contractor, full-time through the National Health Service Corp federal loan repayment program, and been in roles including assistant medical director, co-medical director, medical director, and now as the quality director. It has been rewarding to be part of an organization that has grown from 15 to over 250 employees and from an old, small office building to a 6,000 square foot building. Most recently we opened up a satellite clinic across the river in South Sioux City, Nebraska which is where I primarily see patients now.

Describe the community you serve – what are some of the biggest needs in the community? The biggest barriers to health care?

I love the diversity of the patients that we serve. We have patients from all over the world. We have full time Spanish, Vietnamese, and Somali interpreters. We also serve patients that speak Cambodian, Laotian, Urdu, Aromo, Punjabi, and other languages. I even have a patient from Iceland. I have learned so much from my patients as I have gotten to know them more deeply and have learned of their cultures and traditions. Many of our patients have so many barriers to good health. Some are laborers at the meat processing plants who work long hours and do shift work, and for some assimilation into the local community is difficult.

SCHC_NEWLOGOWhat is the PRAPARE project? Why did Siouxland decide to participate?

PRAPARE stands for “Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences”. It’s an effort that is led by NACHC to create, implement, and promote a standardized tool to assess patient’s social determinants of health – issues like lack of transportation, food insecurity, and homelessness that have significant effects on a person’s health. Dealing with social determinants of health is what health centers do on a daily basis, and we were excited to be part of a project that documented the work we were already doing and gave structure to our efforts.

I feel that we are just scratching the surface of the potential of the PRAPARE project. Population health is so important in today’s healthcare environment. It is not enough to address the immediate needs of the patients that come through our doors each day – we need to determine the state of the health of the community we serve and identify what has the most impact on health outcomes so that we can identify the best ways to improve our patient’s health. There is so much we can do PRAPARE.

What have you discovered about your community with the PRAPARE tool?

We did not have too many surprises with the PRAPARE data. Major areas of need for our patients include transportation, housing, education, food, clothing, and affording medication and other medical costs. The one thing that surprised me the most was that we all know that we deal with patients with social determinants because they are very obvious to us, but there are many patients who deal with these issues but who stay silent unless asked. It was a good experience for me to personally ask the questions on the PRAPARE tool to the patient. It helped me gain a deeper understanding of the patient.

What interventions, programs, and services have you begun to consider as a result of the data you’ve collected with the PRAPARE project?

 We are working with our local regional transit system to identify how we can better overcome transportation barriers for our patients. We have developed workflows and in-house programs to address food and clothing insecurities. We have also been involved in a project to enhance our partnership with Iowa Legal Aid. One of our board members is an attorney who is very involved with Iowa Legal Aid, which has really been a blessing in strengthening this partnership.

 Why are you passionate about the work you do and an advocate for health centers?

I have always felt the desire to work in a profession and for an organization that provides help to those who need it most. Working at the Siouxland Community Health Center has allowed me to do just that. I love that we provide enabling services like case management and health coaches, interpreters, behavioral health, financial, and enrollment counselors. I love the team-based care we provide that includes dental, pharmacy, and behavioral health. I believe that health centers are best equipped to solve many of the healthcare issues we are facing as a nation. I am a firm believer in the community health center concept and I am inspired by stories of the earliest health centers that were started in the Mississippi Delta and inner-city Boston in the 1960’s. I hope we can return to our early community health center roots by aggressively and systematically addressing the social determinants of health that impact the patients we serve. To do this, we need to be able to capture good data on social determinants at a population level, document the enabling services that we provide, and develop new programs and partnerships to overcome the social determinants of health in the communities we serve. Each community has different needs and different resources.

My work at the Siouxland CHC is at times exhausting and frustrating, but the work is fulfilling. The most rewarding aspect of my job is the relationships that I have built over more than 20 years with patients I care for and other health center employees I serve with.

To find out more about NACHC’s PRAPARE project, click here or email Michelle Jester at

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