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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

Strategies for Supporting Health Center Patients Experiencing Food Insecurity
HITEQ Center
/ Categories: Population Health, PH and SDH Concepts, Implementing PHM and SDH, Using Data for PHM and SDH, Value Based Payment

Strategies for Supporting Health Center Patients Experiencing Food Insecurity

Published in May 2021, Updated June 2021

Food insecurity has doubled since the onset of the COVID-19 pandemic in March 2020, and has tripled among families with children. Not having enough access to food is a key contributor to negative health outcomes for adults and children alike, and it is important now more than ever for health centers to identify and support patients who are experiencing food insecurity.
This resource is designed to support health center efforts to identify and assist patients who are experiencing food insecurity. It outlines key considerations around integrating social determinants of health (SDoH)-related screening and intervention into the electronic health record (EHR) workflow, highlights standardized screening tools and data elements to monitor the prevalence of food insecurity among patients, and describes several strategies to meet food-related needs. 

 

The downloadable guide, available in the Documents to Download section below, is split into the following sections, each of which draws on foundational work from health centers and national partners: 

  • Integrate your screening strategy into your EHR workflow-- several case studies are included
  • Select a standardized tool to identify food insecurity-- several tools with their related EHR integration and workflow considerations are outlined
  • Monitoring food insecurity among patients-- tips about coding and dashboarding are provided
  • Connecting patients to available resources

 

Documents to download

Previous Article Panel Management in the Age of Value-Based Care
Next Article Insights from the Field: Key Considerations for Implementing Health Information Exchange
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Tags: Social Determinants of Health SDH value based care SDoH community resources screening food insecurity
Intended AudienceHealth Center Clinicians, Health Center Staff

Related Resources

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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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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