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Resource Overview
Population Health Management requires aggregating patient data from a number of sources, and conducting analytics and modeling to derive actionable insights that translate to increased patient engagement and improved outcomes.  Resources in this section describe data sources that are available to health centers, how to access and integrate them, and ways to enrich them with patient-provided data through health risk assessments and patient engagement technologies.
Getting and Using PHM and SDH Data

Lessons Learned in Social Need Screening

Takeaways and examples from interviews with health centers

Molly Rafferty 0 1737

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

Strategies for Determining the Frequency of Social Need Screening

Resource developed April 2022

Molly Rafferty 0 1540

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Dashboarding Social Needs Data: Support Population Health and Advance Equitable Care through Visual Display of Social Determinants of Health

HITEQ Highlights Webinar

Jodie Albert 0 4465

As health centers work towards providing more patient-centered and equitable care, they are increasingly adopting standardized social needs screening tools, such as PRAPARE and others, to systematically identify the challenges patients face in managing and improving their health, such as food and housing insecurity, transportation barriers, or safety concerns.  This information can be used to make impactful care planning and programmatic changes that lead to improvements in health outcomes, resource utilization, and reimbursement.  Data dashboards help analyze social determinants of health information in visual displays that deepen insights and trigger action towards addressing patient’s social needs, improving population health, and reducing inequities in care.

This webinar provided a foundational overview of social determinants of health dashboard design and presents case studies from health centers leading the way on use of social determinants of health data dashboards to build community partnerships, improve linkages to services outside the four walls of the clinic, and demonstrate the value-based impact of social needs services in improving the health, well-being, and quality of life of communities served.  One health center shared their experience building dashboards and using them in their clinic.

 

SDOH Data Dashboards Module 4: SDOH Dashboard Design - Advanced

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 4690

The Social Determinants of Health Data Dashboards training is a four-module series. Modules range from about 8 minutes to 12 minutes in length. Module four provides advanced-level information on using social determinants of health data and dashboards for facilitating and tracking social needs referrals, conducting predictive analysis with social determinants of health and health outcomes data, and using social determinants of health data to improve reimbursement for addressing social needs.

SDOH Data Dashboards Module 3: SDOH Dashboard Design - Intermediate

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 4624

The Social Determinants of Health Data Dashboards training is a four module series. Modules range from about 8 minutes to 12 minutes in length. Module three provides intermediate level information on collecting social determinants of health data and using data visualization for effective dashboards with stratification of data.

SDOH Data Dashboards Module 1: Introduction to SDOH Dashboard Design

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 5618

The Social Determinants of Health Data Dashboards training is a four module series. Modules range from about 8 minutes to 12 minutes in length. Module one provides an introduction to the role of screening and collecting data on social determinants of health, identifying social determinants of health measures and using data effectively, and assessing organizational data dashboard capability. Subsequent modules provide beginner, intermediate and advanced level considerations and examples for social determinants of health data dashboards. 

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Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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