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Resource Overview

Population Health Management (PHM) is an evolving concept encompassing a suite of emerging technologies to aggregate, analyze and use data to improve clinical and financial outcomes.  PHM tools enable health centers to identify, monitor and target care to patients within a population. Resources in this section provide a conceptual foundation to help health center staff deepen their understanding of PHM and how the social determinants of health can be used to improve outcomes.

PHM and SDH Concepts and Overview Resources

Managed Care Data Checklist

Companion Document to Video Module: Payer Data: The Managed Care Data. Prepared by Starling Advisors for the HITEQ Center in July 2022.

Molly Rafferty 0 434

How to Use This Checklist:
This is a supplement to our Module 2: The Managed Care Data Set, which uses the HCP-LAN APM Framework as its basis. Review both before using this checklist. There are terms used throughout that may be new to you or may benefit from detailed explanations—please visit our Value Based Payment Glossary for basic definitions for a host of key terms.


This checklist will walk you, the health center, through a series of common considerations for contracts you may receive from payers with a specific focus on contracts that include value-based payment components. This document assists organizations in understanding the necessary data and data-related tools for managing population health within a managed care environment. It is a primer on the types of best-practices that are necessary to maximize care delivery models that are responsive to value-based payment programs. Follow this checklist to further your understanding of these considerations and to help flag any outstanding issues for legal and/or consultant review prior to execution.


It is important to understand, contracts can be complicated and no one tool can effectively address all possible contract configurations and their potential issues. Use this as a guide with other resources, access outside expertise when needed, and apply your own knowledge and understanding of your business. It also never hurts to ask the health plan representatives if something is not clearly understood.

Lessons Learned in Social Need Screening

Takeaways and examples from interviews with health centers

Molly Rafferty 0 3999

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.

Strategies for Determining the Frequency of Social Need Screening

Resource developed April 2022

Molly Rafferty 0 3208

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Health Center Case Examples in Coding and Documenting Social Risks: Introduction

Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 7219

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series will present health center case examples that explore the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encourage participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Immigration Case Example | Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 6382

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explore the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encourage participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 6559

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explored the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Intimate Partner Violence Case Example | Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 6257

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explored the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

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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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