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Resource Overview

Population Health Management (PHM) is an evolving concept encompassing a suite of emerging technologies to aggregate, analyze and use data to improve clinical and financial outcomes.  PHM tools enable health centers to identify, monitor and target care to patients within a population. Resources in this section provide a conceptual foundation to help health center staff deepen their understanding of PHM and how the social determinants of health can be used to improve outcomes.

PHM and SDH Concepts and Overview Resources

FHIR 101: Opportunities to Improve Interoperability across Health Centers

HITEQ Highlights Webinar

Jodie Albert 0 11109

Fast Healthcare Interoperability Resources (FHIR) is an HL7® standard for electronic healthcare data exchange. This next generation exchange architecture is advancing interoperability in healthcare. FHIR provides a standard way to express and share information across health centers, providers, and related organizations independent of how local EHRs display or store data. For UDS+ and other information exchange needs, all health centers, PCAs, and HCCNs will want to be familiar with the basics of the HL7 FHIR standard. In this session we will discuss what FHIR is, what it basically does, how it impacts your EHR, and what it might mean to your health center and patients.

Health Center Case Examples in Coding and Documenting Social Risks: Introduction

Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 14968

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series will present health center case examples that explore the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encourage participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Immigration Case Example | Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 13827

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explore the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encourage participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 13286

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explored the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Intimate Partner Violence Case Example | Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

HITEQ Center 0 12630

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explored the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

Health Center Case Examples in Coding and Documenting Social Risks

Roundup of Final Privacy and Data Sharing Considerations and Takeaways | HITEQ Learning Collaborative

HITEQ Center 0 11728

Are you capturing information like immigration or refugee status, intimate partner violence, human trafficking, risk of acquiring HIV through sexual contact or substance use disorder, or other information that brings up questions about how to document or code while respecting the patient’s privacy?

This health center learning collaborative series presented health center case examples that explored the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

Dashboarding Social Needs Data: Support Population Health and Advance Equitable Care through Visual Display of Social Determinants of Health

HITEQ Highlights Webinar

Jodie Albert 0 11389

As health centers work towards providing more patient-centered and equitable care, they are increasingly adopting standardized social needs screening tools, such as PRAPARE and others, to systematically identify the challenges patients face in managing and improving their health, such as food and housing insecurity, transportation barriers, or safety concerns.  This information can be used to make impactful care planning and programmatic changes that lead to improvements in health outcomes, resource utilization, and reimbursement.  Data dashboards help analyze social determinants of health information in visual displays that deepen insights and trigger action towards addressing patient’s social needs, improving population health, and reducing inequities in care.

This webinar provided a foundational overview of social determinants of health dashboard design and presents case studies from health centers leading the way on use of social determinants of health data dashboards to build community partnerships, improve linkages to services outside the four walls of the clinic, and demonstrate the value-based impact of social needs services in improving the health, well-being, and quality of life of communities served.  One health center shared their experience building dashboards and using them in their clinic.

 

SAMHSA 42 CFR Part 2 Revised Rule

HITEQ Highlights Webinar

Molly Rafferty 0 29075

New guidelines from SAMHSA released in July 2020 are designed to improve coordination of care for patients in treatment for substance disorder, while protecting confidentiality against unauthorized disclosure and use of patient information. View this HITEQ webinar on changes to SAMHSA’s 42 CFR Part 2 rule (Part 2) which protects individuals receiving substance use disorder treatment by defining privacy and security requirements for written, electronic and verbal information. This webinar features expert presenters from the University of New Hampshire Institute for Health Policy and Practice and the Center of Excellence for Protected Health Information who present on the new final Part 2 rule and future changes in the CARES Act, including what has changed, what has not changed, what this means for health centers in regard to consents and disclosures, and the implications for care coordination. This presentation also addresses privacy considerations for tele-behavioral health and exceptions during the state of emergency waiver.

Telehealth Considerations and Strategies for Special and Vulnerable Populations

HITEQ Highlights Webinar

Molly Rafferty 0 19273

This webinar focuses on strategies to reach and serve special and vulnerable populations using telehealth. Special and vulnerable populations include Migratory, Seasonal, and Agricultural Workers (MSAW), Older Adults, people experiencing homelessness, people with limited english proficiency, and rural communities with limited access to broadband. We discuss building the awareness, knowledge, and ability of both patients and health center staff to successfully use telehealth to meet the needs of these important groups. Wealso share how telehealth promotes health equity and increases overall access to quality healthcare for special and vulnerable populations.

HITEQ Highlights: Using Health Information Technology to Facilitate SBIRT Service Delivery in Health Centers

Alyssa Carlisle 0 27564

This HITEQ Highlights webinar discussed the use of health information technologies (IT) to facilitate the workflow of providing Screening, Brief Intervention, and Referral to Treatment (SBIRT) services. Focus areas included: coding and billing for SBIRT services, using health IT to enhance SBIRT screening, communication, data capture and documentation, clinical decision support, and information sharing and reporting. The webinar presented examples and experiences of health centers currently using health IT to facilitate effective SBIRT service delivery.

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Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

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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