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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
In the Incubator:  Using Social Determinants Data
HITEQ Center

In the Incubator: Using Social Determinants Data

From the Center for Care Innovations

To thrive in an environment of value-based payment and alternative payment models, health centers are starting to use social determinants data to target care efficiently and effectively.  As part of a project supported by the Center for Care Innovations (CCI) Cultivate Fund program, Petaluma Health Center, a Federally Qualified Health Center, optimized its workflow to collect and use social determinants data to respond to the requirements of new payment models. 

This mini-case study describes Petaluma’s approach to incorporating social determinants data into their daily workflows.  They then used Tableau visualization to represent the data to enable them to target interventions in the community.  Petaluma’s lessons learned and next steps are discussed, and a link to the full, detailed case study is provided.

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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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