Lessons Learned: Implementing and Expanding Social Needs Screening Programs in Health Centers - Session 4: Level 4: Monitoring Population Level Data and Beyond

HITEQ Learning Collaborative Series

This learning collaborative presented by the HITEQ Center, allowed participants to learn about health center promising practices and key considerations to support the successful collection, monitoring, and addressing of social needs data. During the series participants explored the levels of maturity in the social needs screening implementation process. Participants also gained information on concrete strategies and IT solutions that will help to improve internal systems, such as EHR utilization and care team workflows, and increase their capacity to advance individual and population-level health.  Health center exemplars were showcased.

The levels of maturity include: 

• Level 1: Coming to Consensus

• Level 2: Implementing a Social Needs Screening Tool

• Level 3: Responding to Positive Screens

• Level 4: Monitoring and Using Data

Session 4: Level 4: Monitoring Population Level Data and Beyond: Moving Beyond the Health Center's Four Walls

During this session, participants explored what it means to move beyond simply collecting social needs data to participating in ongoing data monitoring and maintenance, and acting on data to  advance population-level health outcomes. 

Topics: Monitoring data, convening leadership to evaluate data, data visualization, data extraction, importance of staff training, improving service delivery, establishing community partnerships, emerging opportunities (risk stratification, advancing value-based care policy).