There is a great deal of interest among health centers, primary care associations and health center controlled networks of the advantages associated with investing in a Population Health Management (PHM) electronic platform. Measuring specific and quantifiable returns clarifies the benefits and supports a consistent understanding among stakeholders of the value of PHM. During this webinar, we discussed the Michigan HCCN’s experience with putting the components in place to measure the return on investment (ROI) of their PHM support program. The HITEQ Center also introduced a newly developed PHM ROI matrix tool. The PHM ROI Matrix Tool is intended to “walk” an organization through a process of developing the ability to measure benefit in basic, intermediate, or advanced terms.

Interested in office hours to ask our presenters further follow-up questions? Please register here for the March 22, 2018 Office Hours.

The Road to Sustainability for SDOH Interventions

Presented by: National Nurse-Led Care Consortium, Corporation for Supportive Housing, Health Outreach Partners and National Association for Community Health Centers

Health Centers are developing a variety of innovative ways to address SDOH. Commonly the greatest challenge to this work is having a sustainable funding stream to take and keep the work at scale. This webinar highlighted funding models and funding mechanisms that could assist in SDOH activities, as well as the partnerships and activities that can assist your health center in sustaining these important activities. The presenters described funding models that support SDOH work and examples of health centers activities that had led to sustainable funding for SDOH activities.

By the end of this session, participants will be able to:

• Describe the principles of funding models such as Value Based Payments, Alternative Payment models and other examples of funding models that support SDOH activities.
• Explain how integrated care teams can be developed to prepare for Value Based Payment models.
• Learn examples of data collection variables and methods that can incorporated in to your health center’s workflow to collect the information your health center needs to engage funders and payment systems.
• Learn examples of tools and resources that can help your health center build the case for SDOH activities.

Population Specific Approaches to SDOH

Presented by: Harvard Equitable Care for Elders, National LGBT Health Education Center, Migrant Clinicians Network and National Center for Health in Public Housing

Type 2 diabetes is a chronic disease which places individuals at risk for serious long term complications and death. Risk reduction, effective treatment and management of diabetes as with many other chronic diseases are heavily dependent on social and environmental conditions. Individuals within certain special and vulnerable populations experience health inequalities and therefore are at a higher risk of late detection, inadequate management and treatment of diabetes. Improved access to certain non-clinical enabling services and a comprehensive social history is essential to understanding the needs of these often overlooked individuals, and developing interventions that address those needs. During this webinar, presenters will provide an introduction to the unique and common challenges facing this population and strategies to adapt and increase access to social enabling services.

By the end of this webinar, participants will be able to:

• Describe the impact of mobility as a social determinant of health that impacts the identification, treatment, and management of diabetes. Participants will also identify at least one resource to increase continuity of care for mobile diabetic patients.
• Articulate the social characteristics of and risk factors for diabetes in public housing residents.
• Describe the impact of social determinants of health specifically experienced by LGBTQ patients on management of diabetes and diabetes outcomes among LGBTQ patients.
•  Articulate the key role social determinants play in addressing the long term management of older adults diagnosed with Type 2 diabetes and other co-morbidities.

Pathways to Cross-Sector Partnerships to Address SDOH, Part 2

Presented By: National Center for Medical-Legal Partnership School-Based Health Alliance

Since their inception, health centers have had a special focus on identifying and addressing patients' health-related social needs in an effort to ensure optimal access to primary care. In a rapidly changing, and infinitely more complex social and health landscape, it is more important than ever that our care teams and tools evolve to meet patients where they are. As health centers work to improve their social determinants of health strategies, strategies, they must adapt new ways to solve age-old problems like poor housing and lack of income, which reverberate for health center patients and result in poor health outcomes. Join this webinar for a broad discussion of the opportunities to tackle SDOH in tandem with existing community partners and how health care teams can work together to address the social determinants of health. Special focus will be given to school-based and legal interventions that can meet the needs of patients and boost capacity of the healthcare team confronting complex SDOH. The session will review specific resources and tools. Presenters will also discuss how the above interventions can inform the dynamics and challenges of diabetes management for a range of populations.

By the end of this webinar, participants will be able to:

• Demonstrate how healthcare teams bridging across sectors like law and education can support increased access to care, improve health services delivery, and improve overall health outcomes with a focus on diabetes management.
• Identify resources available to meet the needs of pediatric and adolescent patients.
• Understand the connection between legal and health needs.

Pathways to Cross-Sector Partnerships to Address SDOH, Part 1

Presented by: Cooperation for Supportive Housing (CSH) and National Health Care for the Homeless Council

Food security and having access to safe, affordable housing are two of the most basic and yet powerful SDOH. As more and more health centers begin to screen for specific SDOH which includes housing and food security, health centers need to be equipped to triage and connect patients to appropriate partners in their local community. This webinar will highlight health centers who have developed strong relationships with local community based organizations (CBOs) to address the lack of stable housing and food for their patients; including patients with diabetes. The presenters will share examples of health centers who have built cross -sector partnerships with supportive housing providers, hospitals, and/or managed care organizations, food pantries, and soup kitchens to meet the medical and social needs of their more complex patients.

By the end of this session, participants will be able to:

• Explain how supportive housing providers can connect individuals to health centers for clinical services.
• Define food security.
• Identify promising practices for building cross-sector partnerships, to address the housing and nutritional needs of vulnerable populations, which includes patients with diabetes.
• Describe how the lack of access to safe housing and proper nutrition impacts the quality of care provided and chronic disease management.