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Resource Overview
There are many tools available and a number of vendors serving the market for PHM technologies, making implementation decisions and planning a challenge for health centers.  Resources in this section provide a framework for PHM vendor selection and a roadmap for PHM and SDH implementation.  Case examples are provided to demonstrate health centers’ experiences implementing PHM and SDH.
Implementation of PHM and SDH Resources

Utilizing and Integrating Behavioral Health Data into a Health Center’s Primary Care Services

A profile of health center experiences, developed with Chiron Strategy Group

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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.

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

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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.

 

The Value Proposition for Population Health Management for Health Centers

Calculating ROI on your PHM investment

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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.

Telehealth Strategies and Resources for Serving Patients with Limited English Proficiency

Published June 2020

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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. 

Strategies for Supporting Health Center Patients Experiencing Food Insecurity

Published in May 2021, Updated June 2021

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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

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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.

SDOH Data Dashboards Module 4: SDOH Dashboard Design - Advanced

HITEQ SDOH Data Dashboards Series

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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

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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. 

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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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