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.

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.

For many, telehealth has removed barriers and ensured that people receive care when and where it is most convenient. However, while telehealth can remove obstacles, if not used deliberately and thoughtfully, it can exacerbate many inequalities that exist in the United States. One factor that is essential to account for is language accessibility, which, if not provided, limits the number of patients who are able to utilize telehealth services. 

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. 

Establishing a social need screening program requires buy-in from both leadership and staff. This resource shares examples of strategies gleaned from interviews with health centers.

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.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

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.

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.

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.