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Overview

Data monitoring, from the highest level down to the patient level is critical to identifying trends, gaining insights, and communicating transparently with staff and stakeholders. Data monitoring approaches such as dashboarding are used to display data in a simple and intuitive way, allowing a snapshot of performance on selected measures to see changes or areas for improvement. Business intelligence systems such as population health management analytics allows for the monitoring of the health of a whole patient population, stratified by various characteristics, thereby supporting care planning, resource allocation, and training opportunities. Resources in this section include tools to begin dashboarding, considerations for taking the next step with population health management and guidance on how to navigate the many factors of any data monitoring approach.

Monitoring and Communicating with Data
Event date: 3/9/2023 12:00 PM - 1:00 PM Export event
Lessons Learned: Implementing and Expanding Social Needs Screening Programs in Health Centers - Session 3: Level 3: Responding to the Social Needs Screening
Jodie Albert
/ Categories: Population Health

Lessons Learned: Implementing and Expanding Social Needs Screening Programs in Health Centers - Session 3: Level 3: Responding to the Social Needs Screening

HITEQ Learning Collaborative Series

Is your health center currently in the process of considering, implementing, or revamping a social needs screening program within your EHR or health IT system? Join this learning collaborative 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 will explore the levels of maturity in the social needs screening implementation process.

 

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

Participants will gain 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.  The HITEQ Center has partnered with the Louisiana Primary Care Association to design this series. Louisiana-based health centers will be showcased throughout the series to share their experiences with social needs screening, including successes, challenges, and lessons learned.

Session 3: Level 3 - Responding to the Social Needs Screening
During this session, participants will learn about concrete digital solutions health centers can leverage to document, communicate, respond to, and track positive screens.

Topics: Documenting positive screens (via order sets, Z codes, problem lists, favorites group), Sensitivity with Z codes, Communicating positive screens (internal referrals, telephone encounters, global alerts, castover), Responding to positive screens (internal and external referrals, role of behavioral health or case management department, challenges with community-based referral platforms, tracking referrals), Prioritizing which positive needs to address.

 

 

 

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Acknowledgements

This resource collection was compiled by the HITEQ Center staff with guidance from HITEQ Advisory Committee members and collaborators of the HITEQ Center.

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Quadruple Aim

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Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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