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.

HITEQ is actively compiling a telehealth resource library for health centers, which houses actionable telehealth resources in the areas of telehealth technology, patient use of telehealth, provider use of telehealth, tele-behavioral health, and operationalizing telehealth more generally. This curated set of resources aims to assist health centers in accessing those resources that directly address current telehealth needs and challenges.

This worksheet is a key component of the Guide to Improving Care Processes and Outcomes in Health Centers, developed by TMIT Consulting, LLC and the HITEQ Center.

A helpful QI adage is that “systems are perfectly designed to produce the results they deliver.” This truism highlights the importance of understanding current care processes that are driving sub-optimal performance on the targeted measure so they can be refined to deliver better results. The CDS/QI worksheet supports this analysis through a structured, broadly applicable framework for documenting, analyzing, sharing and improving target-focused care activities.

This case study presents the PHM implementation story of La Maestra Community Health Centers (LMCHC), located in San Diego, California.

This case study presents the PHM implementation story of Health Care for the Homeless (HCH), a Baltimore-based safety net provider.  HCH implemented Azara DRVS, a PHM solution that offers centralized data reporting and analytics for health centers and primary care associations.  Azara DRVS turns EHR data into reports for population health, chronic disease management, care planning, QI, risk and cost monitoring and regulatory compliance and reporting including UDS, Meaningful Use and PCMH.