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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
Social Determinants of Health (SDoH) Toolkit
HITEQ Center
/ Categories: Health IT Enabled QI, Improving Performance, Population Health, PH and SDH Concepts, Implementing PHM and SDH, Improving PHM and SDH Quality

Social Determinants of Health (SDoH) Toolkit

Prepare, Test, and Spread: Experiences Implementing PRAPARE in Iowa

This toolkit from Iowa’s Primary Care Association as part of the State Innovation Model is organized around the three stages of SDOH: Prepare, Test and Spread. The key concepts are organized under each of the stages. This toolkit provides existing and new tools for each of the 21 concepts with guidance related to when an organization may want to use each tool or concept. Links to previously developed tools are included in the concept areas but are also included in the toolkit as websites and electronic resources because URLs tend to move or “break” over time. The 21 concepts covered in the toolkit are as follows:

PREPARE

  • Understand the community
  • Align with strategic plan
  • Assess your organization
  • Pick a tool
  • Practice asking questions
  • Find your clinical champion
  • Create your resource matrix
  • Brainstorm workflows
  • Script for all audiences
  • Ensure support for staff

TEST

  • Test your reporting
  • Trial workflows
  • Track progress
  • Get feedback from patients
  • Monitor referral completion

SPREAD

  • Continuous quality improvement (CQI)
  • Share your story
  • Develop new partnerships
  • Advocate for population level resources and policy changes

Resource Links

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Tags: Social Determinants of Health social determinants SDoH Implementation Guide referral to community partners social need

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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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