As more health centers seek to break down siloes that can fragment patient care, collaboration with or integration of behavioral health care has been strengthened, although data integration remains difficult and privacy remains paramount. This brief discusses some of the approaches, successes, and challenges in integrating behavioral health data within primary care services.

The collection of data related to patients' non-medical needs through use of Social Determinant of Health (SDoH) assessment tools, can accelerate systemic population health improvement, as well as engage patients in addressing their social non-medical needs (such as transportation, shelter, or intimate partner violence services) through coordinated access to appropriate services. This case study discusses the process a health center may use to identify and stratify need, and profiles a number of new technologies, including Aunt Bertha, Now Pow, and 211 Community Information Exchange, for connecting patients to appropriate community resources.

This resource will equip health center stakeholders with the understanding of what data-related capacity is needed to succeed under risk-based payment models.

Measuring return on investment (ROI) and the value of population health management is an emerging concern for health centers.  Calculating ROI on HIT investment is complex, and few health centers have experience in this endeavor.  The definition of value varies by type and size of provider, patient population, and other factors, and may be unique to an organization.  This white paper discusses principles and approaches to measure the value proposition for population health management for health centers.  Although few examples exist, we present the results of one health center’s measurement of the value of PHM.