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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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Resource Overview

Patient portals, sometimes also referred to as personal health record systems (PHR) are web-based portals commonly attached to electronic health record systems (EHRs). These patient-centered portals provide patients with the ability to login and review health information related to their care. Common patient portal services include ways in which to schedule appointments, send messages to their care providers, review test results and refill prescriptions.

Outside of the benefits to the patient, implementation of patient portals had come to the attention of healthcare providers due to the inclusion of Meaningful Use of objectives centered on the use of patient portals and electronic engagement with patients.  Stage 3 requirements are still being explored and the impact it will have on Health Centers is unknown. Therefore, it is a challenge for small practices and Health Centers to determine how to best derive value from Patient Portals and effectively implement them into their workflow.

The tools and articles posted below are meant to provide examples, templates and strategies that can assist Health Centers in understanding how patient portals can better engage their patients in self-management of their care, and after an initial investment in time and money can decrease the burden on their clinical and administrative staff.

Patient Portal Resources

Lessons Learned in Social Need Screening

Lessons Learned in Social Need Screening

Takeaways and examples from interviews with health centers

Download the full Lessons Learned publication in the Documents to Download section below. 

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.

In an effort to better address patients’ social needs, health centers are turning to screening tools such as Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE), among others, to collect a wide range of social needs data. This information can be used to inform clinical decision making, develop internal programming, and refer patients to community-based resources. Despite recent momentum in the area of social needs screening, implementation at community health centers continues to be varied and uneven, and many are looking for guidance from peers on how to screen for social needs and respond to positive screens.

HITEQ explored the current landscape of social need screening implementation by first reviewing recent literature and publications. This information was then contextualized in past experiences and conversations with health centers, ultimately building upon our existing knowledge of the drivers, opportunities, and challenges of social needs screening.

To take a deeper dive, HITEQ conducted interviews with eleven health centers in Fall 2021. We specifically reached out to selected health centers that successfully reported across all four categories of social need in the 2020 Uniform Data System (UDS) report, therefore indicating some level of consistent deployment of social need screening. These UDS categories include food insecurity, housing insecurity, financial strain, and lack of transportation or access to public transportation. The health centers interviewed represented different states and localities, as well as different population and catchment sizes.

This resource is designed to support health centers by outlining promising practices that were illuminated in the interviews with health centers who found success implementing their social need screening programs. In particular, the interviews brought to light that to implement an integrated screening program that produces high-quality data, health centers must utilize digital health solutions and leverage their electronic health record (EHR). This resource shares examples of these solutions in practice, and is designed to equip health centers with the information necessary to implement a screening program that limits burden on staff, is meaningful for patients and their care, and advances population health.

The digital solutions presented can be used to help health centers begin conceptualizing their social need screening program, and support health centers with existing programs to identify gaps and opportunities for improvement. How health centers apply the information detailed in this resource will depend on their capacity, resources, workflows, and level of readiness.

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Documents to download

Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable suggestions and contributions from HITEQ Project collaborators.