Resource Overview
Population Health Management requires aggregating patient data from a number of sources, and conducting analytics and modeling to derive actionable insights that translate to increased patient engagement and improved outcomes.  Resources in this section describe data sources that are available to health centers, how to access and integrate them, and ways to enrich them with patient-provided data through health risk assessments and patient engagement technologies.
Getting and Using PHM and SDH Data

Risk Stratification Approach

Population Health Management Action Guide from NACHC

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Risk stratification enables providers to identify the right level of care and services for distinct subgroups of patients. It is the process of assigning a risk status to a patient and then using this information to direct care and improve overall health outcomes. NACHC's Action Guide lays out 4 steps to get you started with risk stratification as well as key related concepts and considerations. 

Population Health Curriculum

From the Robert Graham Center, HealthLandscape, American Board of Family Medicine, and Community Health Center, Inc.

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This curriculum aimed to introduce health care professionals to population health concepts and tools. Resources include slides and note sets, three case studies with sample data, and a performance improvement activity.

Data Dictionary Tool and Template

Organizational tool for your EHR and analytics platform data indicators

HITEQ Center 0 6923

This Data Dictionary provides a single point of reference for data mapping and interpretation for all of the indicators in your quality reports. Organization of the data definitions in this tool provides a reference for the team of all such definitions that impact reports and alerts in the analytics application.

Demystifying Predictive Analytics

Factsheet on Predictive Analytics for Health Centers

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Using predictive analytics in health care is an emerging field, especially for health centers. This tool will provide a brief explanation of the purpose of predictive analytics, the ingredients necessary to apply these methods, and ways that health centers are using this approach to improve results. The objective of this resource is to help health center leadership and staff understand how and when predictive analytics can help them, and to think about how predictive analytics might fit into their data-driven QI program.

Results of Population Health Analytics/ Data Integration Survey

PCA/ HCCN Experiences Assessing and/ or Implementing Systems

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HITEQ conducted an anonymous survey of population health analytic and data integration system needs and impressions among PCA/HCCNs in late 2016 and early 2017. The results of that survey, intended to help those looking to adopt similar systems, are laid out within. This includes ratings of key functionalities, discussion of most important features, and comments from those who have assessed and/ or implemented these tools.

Understanding Data Elements and Outcome Measures in Health and Housing Partnerships

Corporation for Supportive Housing

Alyssa Thomas 0 3276

As partnerships between health centers and supportive housing providers continue to grow across the country, so do reports of reduction in crisis service utilization and health system costs. We are seeing evidence that Housing First programs improve mental health and substance use outcomes. Simultaneously, there is still a need to expand understandings of the impact of housing on clinical measures. This webinar explored health outcomes and data measures that health centers can track as part of a housing partnership, and discussed how health and housing partners are using data to gain a greater understanding of the impact.

Using your EHR for Population Health Management

A Cross-reference Tool

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Health centers are interested in managing population health but may not have the budget needed to purchase specialty suites. This tool will guide health centers in leveraging the “built in” functionality of certified EHRs to perform PHM functions by mapping the native PHM functionality available in the common certified EHRs used by health centers.  The aim is to help health centers to understand where to start in implementing PHM using what they already have available to them.


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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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