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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

Demystifying Predictive Analytics

Factsheet on Predictive Analytics for Health Centers

HITEQ Center 0 29

Using predictive analytics in health care is an emerging field, especially for health centers. This tool will provide a brief explanation of the purpose of predictive analytics, the ingredients necessary to apply these methods, and ways that health centers are using this approach to improve results. The objective of this resource is to help health center leadership and staff understand how and when predictive analytics can help them, and to think about how predictive analytics might fit into their data-driven QI program.

Results of Population Health Analytics/ Data Integration Survey

PCA/ HCCN Experiences Assessing and/ or Implementing Systems

HITEQ Center 0 123

HITEQ conducted an anonymous survey of population health analytic and data integration system needs and impressions among PCA/HCCNs in late 2016 and early 2017. The results of that survey, intended to help those looking to adopt similar systems, are laid out within. This includes ratings of key functionalities, discussion of most important features, and comments from those who have assessed and/ or implemented these tools.

Understanding Data Elements and Outcome Measures in Health and Housing Partnerships

A Corporation for Supportive Housing Webinar

Alyssa Thomas 0 137

As partnerships between health centers and supportive housing providers continue to grow across the country, so do reports of reduction in crisis service utilization and health system costs. We are seeing evidence that Housing First programs improve mental health and substance use outcomes. Simultaneously, there is still a need to expand understandings of the impact of housing on clinical measures. This webinar will explore health outcomes and data measures that health centers can track as part of a housing partnership, and will discuss how health and housing partners are using data to gain a greater understanding of the impact.

Using your EHR for Population Health Management

A Cross-reference Tool

HITEQ Center 0 282

Health centers are interested in managing population health but may not have the budget needed to purchase specialty suites. This tool will guide health centers in leveraging the “built in” functionality of certified EHRs to perform PHM functions by mapping the native PHM functionality available in the common certified EHRs used by health centers.  The aim is to help health centers to understand where to start in implementing PHM using what they already have available to them.

Predictive Analytics: An Overview for Community Health Centers

from Capital Link

HITEQ Center 0 364

Capital Link has published this overview of predictive analytics for community health centers.

Developed and made available by Capital Link and the National Association of Community Health Centers (NACHC), this overview provides health centers with a definition of predictive analytics, its history and development, the data and resources needed to predict a patient’s future behavior, and how health centers can begin utilizing it. It also includes specific examples of organizations that have successfully used predictive analytics. This study was supported by the Health Resources and Services Administration. 

Community Health Assessment for Population Health Improvement

from CDC

HITEQ Center 0 613

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 Power of Demographic Data

From the Center for Care Innovations

HITEQ Center 0 382

This features a presentation entitled “The Power of Demographic Data:  Leveraging Demographic Data to Increase Access in a Data-Driven Culture”,  and is one of five presenting use cases for analytics.  It was recorded during the Safety Net Analytics Program of 2015 that discusses real-world applications of analytics emerging under new payment models. The use cases presented are health-center specific and provide examples of validating and applying UDS data entities.  The discussion includes ways to gather demographic data from patients, how to collect usable data, extracting actionable data and the implications of demographic variation on care and information delivery.

In the Incubator: Using Social Determinants Data

From the Center for Care Innovations

HITEQ Center 0 340

This mini-case study describes Petaluma Health Center, a Federally Qualified Health Center’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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