Data Storyteller

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.

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.

Empanelment is the basis for population health management and the key to continuity of care. Accepting responsibility for a finite number of patients, instead of the universe of patients seeking care in the practice, allows the provider and care team to focus more directly on the needs of each patient. Inside, find guidance for establishing and maintaining patient panels.