Behavioral Health Integrator

With nearly 100% of community health centers utilizing electronic health records (EHR) to care for patients, focus has pivoted from implementation and new workflow development to enhancement in order to drive value and reflect patient needs and population trends. EHR technology presents potential opportunities and significant constraints. Providers frequently document and share potentially sensitive information in the EHR, such as risk for intimate partner violence (IPV), consistent offers of pre-exposure prophylaxis (PrEP), or patient sexual orientation and gender identity (SOGI). Capturing such information can be immensely helpful in providing care tailored to individuals’ needs, but additionally challenges teams to develop workflows that keep the data private rather than risk harm to patients through improper or unintended disclosure.

Health centers are increasingly interested in embedding oral Pre-Exposure Prophylaxis (PrEP) programs into primary care, which calls for the embedding of PrEP care processes into electronic health record (EHR) systems. Health centers have had success with automation in HIV testing, and are looking to apply automated algorithms, order sets, and templates to the development of PrEP programs. This resource outlines EHR and health information technology (IT) configurations and tools that support PrEP care processes and provides examples of successful implementation from health centers and primary care settings.

This spreadsheet developed by the HITEQ Center provides a crosswalk of Clinical Quality Measures and their electronic specifications as defined in the 2023 update for Eligible Professionals (Clinicians). Fields include the crosswalk of measures with related information about CMS, NQF, and MIPS ID, and Telehealth Eligiblity, as well as inclusion in HRSA BPHC Uniform Data System (UDS) CY2023, Million Hearts, CMS Quality Payment Program (QPP) -  APM Performance Pathway (APP) Measures, Medicare Shared Savings Program (MSSP)/ CMS ACO Shared Savings Program, CMS Core Set (Child Core Set Medicaid / CHIP): HEDIS Specified, CMS Core Set (Adult  Core Set Medicaid): HEDIS Specified, Core Quality Measures Collaborative (ACO / Primary Care). Links are included throughout.

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.

In this video, viewers will learn how People, Process and Technology should factor into a health center's social needs screening workflow