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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

SDOH Data Dashboards Module 4: SDOH Dashboard Design - Advanced

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 468

The Social Determinants of Health Data Dashboards training is a four-module series. Modules range from about 8 minutes to 12 minutes in length. Module four provides advanced-level information on using social determinants of health data and dashboards for facilitating and tracking social needs referrals, conducting predictive analysis with social determinants of health and health outcomes data, and using social determinants of health data to improve reimbursement for addressing social needs.

SDOH Data Dashboards Module 3: SDOH Dashboard Design - Intermediate

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 478

The Social Determinants of Health Data Dashboards training is a four module series. Modules range from about 8 minutes to 12 minutes in length. Module three provides intermediate level information on collecting social determinants of health data and using data visualization for effective dashboards with stratification of data.

SDOH Data Dashboards Module 1: Introduction to SDOH Dashboard Design

HITEQ SDOH Data Dashboards Series

Molly Rafferty 0 569

The Social Determinants of Health Data Dashboards training is a four module series. Modules range from about 8 minutes to 12 minutes in length. Module one provides an introduction to the role of screening and collecting data on social determinants of health, identifying social determinants of health measures and using data effectively, and assessing organizational data dashboard capability. Subsequent modules provide beginner, intermediate and advanced level considerations and examples for social determinants of health data dashboards. 

Making a Good First Impression: Digital Patient Intake Solutions

How Health Centers can Use Digital Intake Tools to Support Social Determinants of Health Data Collection

Molly Rafferty 0 1501

Now more than ever, health centers know that addressing social determinants of health is key to ensuring patients from underserved and disadvantaged groups receive quality, informed, and comprehensive care. This resource explores how health centers can effectively and safely collect critical patient information, including sensitive information like social need screening, through digital patient intake solutions that rely on paper-free, data-smart registration and EHR integration. Health centers can walk through why adding these solutions to their clinics can engage rather than alienate patients, and how to implement these technologies to screen for social risk and improve the patient experience.

The resource is available in the Documents to Download section below.

Strategies for Supporting Health Center Patients Experiencing Food Insecurity

Published in May 2021, Updated June 2021

HITEQ Center 0 3718

Food insecurity has doubled since the onset of the COVID-19 pandemic in March 2020, and has tripled among families with children. Not having enough access to food is a key contributor to negative health outcomes for adults and children alike, and it is important now more than ever for health centers to identify and support patients who are experiencing food insecurity.
This resource is designed to support health center efforts to identify and assist patients who are experiencing food insecurity. It outlines key considerations around integrating social determinants of health (SDoH)-related screening and intervention into the electronic health record (EHR) workflow, highlights standardized screening tools and data elements to monitor the prevalence of food insecurity among patients, and describes several strategies to meet food-related needs. 

Social Determinants of Health (SDoH) Toolkit

Prepare, Test, and Spread: Experiences Implementing PRAPARE in Iowa

HITEQ Center 0 4755

This toolkit from Iowa is organized around the three stages of SDOH: Prepare, Test and Spread. The key concepts are organized under each of the stages. This toolkit provides existing and
new tools for each of the 21 concepts with guidance related to when an organization may want to use each tool or concept.

Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources

We asked the questions, now what? Updated in December 2018

HITEQ Center 0 25847

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.

 

Population Health Curriculum

From the Robert Graham Center, HealthLandscape, American Board of Family Medicine, and Community Health Center, Inc.

HITEQ Center 0 22914

This curriculum aimed to introduce health care professionals to population health concepts and tools. Resources include slides and note sets, three case studies with sample data, and a performance improvement activity.

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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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