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.

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

Health centers now report on social determinant of health screening activities and many use the PRAPARE tool for this purpose; for years, however, health centers have focused on the broader health and social needs of the individuals they serve often making referrals to community based organizations and utilizing available enabling services. Today, there is growing interest and awareness on the value and use of interoperable social determinants of health (SDoH) data to support individual, community, and population level health improvement. View this HITEQ Center webinar, where the The Health and Human Services, Office of the National Coordinator for Health IT present on the current state of federal activities and standards based approaches for collecting, sharing, and using SDoH data with a focus on technical and policy considerations. The presentation describes available standards, tools, and initiatives for health center use and input.

Health centers are interested in using social determinants data to manage and improve the health of their patient population and community, and are at different places on the population health management (PHM) and social determinants of health (SDH) adoption curve. The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. In this webinar, the Colorado Community Managed Care Network (CCMCN), a Health Center Controlled Network (HCCN) highlighted a Tableau data dashboard that they have developed to help their health centers make decisions on population health management. They discussed the rationale for developing the tool, challenges and facilitators to integration, and how their health centers benefit from data sharing across Tableau.