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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
Community Health Assessment for Population Health Improvement

Community Health Assessment for Population Health Improvement

from CDC

Targeting care and effective planning for improving population health requires good information about current health status and the factors that will influence that health status.  This report identifies the metrics – the population health outcomes and important risk and protective factors – that, taken together, can describe the health of a community and drive action. Selection of these metrics is  based on a systematic review of professional and academic judgment over the past three decades.  The report identifies 42 metrics, broadly categorized as those characterizing the status of health outcomes or health determinants. This report also contains links to and descriptions of existing sources of indicators for these metrics. The majority of the 42 metrics have indicators available at the level of metropolitan statistical area, county, or sub-county (census tract, census block groups).

A population health framework is used to organize the metrics of health outcomes and determinants. Outcomes were categorized as mortality or morbidity. Social determinants were organized into the following categories: health care, personal behaviors, demographics and the social environment, and the physical environment.  These indicators can be used to make comparisons across populations, promote collaboration between organizations conducting assessments, assist in establishing a shared understanding of the factors that influence health, and help to galvanize residents to work collaboratively to improve community health.

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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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