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
Event date: 10/25/2016 3:00 PM - 4:00 PM Export event
Ask & Code: Documenting Homelessness Throughout the Health Care System
Alyssa Thomas

Ask & Code: Documenting Homelessness Throughout the Health Care System

A National Health Care for the Homeless Council Webinar

All sectors of the health care system are increasingly focused on the social determinants of health that drive cost, service utilization, and health outcomes. Housing status, as one key element of health, is a risk factor that is of particular interest to hospitals, Medicaid managed care plans, and health care providers. People experiencing homelessness have higher morbidity and mortality coupled with more frequent and more costly hospital stays compared to their housed counterparts, driving the interest in improving care and reducing cost. To help justify funding additional services (e.g., case management, medical respite care, and housing supports) that will improve patient health status, better data is needed to identify individuals who are homeless. This webinar complements our recent policy brief and will discuss how the ICD-10-CM code for homelessness (Z59.0) has been implemented at a Health Care for the Homeless grantee in Colorado, and how a hospital system has instituted a housing status screening tool in Pennsylvania. Finally, we’ll hear from a leading managed care entity about why Medicaid plans need to have this information and see preliminary results from a pilot project in Texas using the Z59.0 code to identify homelessness among Medicaid beneficiaries.


  • Understand why health centers, hospital systems and managed care organizations would want patient housing status information and coded homelessness data
  • Identify at least three strategies for implementing an “ask and code” approach in a health care setting
  • Identify potential uses for this data to gain additional services for people who are homeless and/or benefits to homeless health care providers


  • Tracy Olsten, CPC, CPC-I, CPMA, Senior Coding Specialist, Colorado Coalition for the Homeless, Denver, CO
  • Brett Feldman, MSPAS, PA-C, Director, Street Medicine, Lehigh Valley Health Network, Allentown, PA
  • Jenny Ismert, Vice President Health Policy, UnitedHealthcare Community & State
  • Moderator: Barbara DiPietro, PhD, Senior Director of Policy, National HCH Council

*Please add Council@nhchc.org to your "Safe Senders" list to ensure delivery of registration confirmation.

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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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