ENVIRONMENTAL DRIVERS

Social Determinants of Health (SDoH)
In describing Social Determinants of Health, the World Health Organization writes: “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”  Improving population health requires that requires that the social, cultural, and economic forces that impact health status be assessed and addressed through community-level action. 

• The Essential Needs Roadmap (Health Leads, 2018)
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  Designed in collaboration with Kaiser Permanente and a group of health system leaders working to strengthen effective initiatives to address social determinants of health , the Essential Needs Roadmap consists of a curated library of tools, best practices, implementation guidance, and other dynamic content to support health care organizations focused on addressing essential social health needs. It is organized into six categories that are critical to successful strategies: ID and Screening; Navigation & Resource Connection; Social Health Team & Workflow; Community Partnerships; Data and Evaluation; and Leadership & Change Management.
• Community Health Centers Leveraging the Social Determinants of Health (Institute for Alternative Futures, March 2012)
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  In the context of an increasing focus on the social determinants in federal health policy, academic research, and emerging care models, this report, developed by the Institute for Alternative Futures (IAF) and the National Association of Community Health Centers (NACHC), with the support of the Kresge Foundation, provides a systematic overview of community health center approaches to addressing a range of community and social conditions, incorporating a database of 176 activities, projects, programs, and interventions by 52 different health centers as of printing date, as well as in-depth case studies of 10 CHCs. It offers leaders in community health centers, public health, and policy an understanding of how health care providers can move beyond health care services alone to care for the whole person and their community and concludes with recommendations developed at a national workshop of CHC leaders and other experts to expand and enhance these efforts.
• Medical-Legal Partnership and Health Centers: Addressing Patients’ Health-Harming Civil Legal Needs as Part of Primary Care (Marsha Regenstein, Joel Teitelbaum, Jessica Sharac & Ei Phyu, National Center for Medical-Legal Partnership, February 2015)
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  Legal expertise and services can play a critical role in helping the health care system address the root cause of some of the most challenging problems related to health and health care delivery and utilization; medical-legal partnerships integrate the expertise of health care, public health and legal professionals and staff to address and prevent health-harming civil legal needs for patients, clinics and populations. The National Center for Medical-Legal Partnership leads education, research, and technical assistance efforts to help health organizations leverage legal services as a standard part of the way they respond to social needs. This issue brief explores the medical-legal partnership approach in the context of health centers.  It is intended to help health centers understand the benefits – to patients and to their institutions – of partnerships with civil legal aid agencies, and to introduce additional resources that can help health centers implement these programs. “Applying the MLP Approach to Population Health, Pain Points, Payment Reform (2016)” is a related brief.
• Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)
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  A national, multi-year effort to help community health centers collect meaningful data on social determinants of health and respond to community needs.  Created as an open-source tool through a collaborative stakeholder-involved process, PRAPARE consists of a set of national core measures and optional measures aligned with national initiatives. Templates are available for electronic health record applications including EPIC, NEXT GEN, eClinicalWorks and GE Centricity. PRAPARE was developed by National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations (AAPCHO), and the Oregon Primary Care Association with funding support from the Kresge Foundation, Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation, and Blue Shield of California Foundation. PRAPARE resources are available at http://www.nachc.org/research-and-data/prapare/toolkit/.
• Social Determinants of Health Needs Assessment Survey and Staff Assessment (Colorado Community Health Network. 2015)
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  These tools are part of a comprehensive guide, “Patient Engagement: A toolkit from the Colorado Community Health Network.” The needs assessment survey is intended to help organizations gauge and enhance the patient’s understanding and knowledge of the social determinants of health (SDoH) in the community in which they live and/or receive care; elicit feedback and information from patients about the SDoH-related barriers to health and identify and discuss practical opportunities for the CHC to recognize and address the SDoH.The staff assessment component may be used to: 1) Gauge and enhance the health center’s understanding of the SDoH; 2) Elicit feedback and information from patients and staff about the SDoH-related barriers to health; and 3) Identify and discuss practical opportunities for the CHC to recognize and address the SDoH.
• Policy Reports: An Overview of Food Insecurity Coding in Health Care Settings: Existing and Emerging Opportunities (Hunger Vital Sign National Community of Practice. January 2018)
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  This report from Food Research & Action Center and Children’s HealthWatch reviews existing and emerging opportunities to document food insecurity screening, assessment, intervention, and billing for each part of a patient visit using discrete codes and language from standardized EHR medical vocabularies.
• A New Way to Talk about the Social Determinants of Health (Robert Wood Johnson Foundation, Carger E., and Westen D., January 1, 2010).
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  This guide, developed by the Robert Wood Johnson Foundation (RWJF), is the product of an in-depth research and communications effort focused on effectively communicating an understanding of social determinants of health and their role in determining health outcomes. The guide discusses why we need a better way to talk about the social determinants of health, and offers best practices on how to engage in effective conversation with different audiences around the concept. It also includes an overview of key research findings from the project and the methodology that was employed.

Partnerships & Multi-Stakeholder Collaboratives/Coalitions
Effective population health management requires local and regional partnerships that support coordination or integration of services, information sharing, leveraging resources, and raising awareness and participation at the community level.

• Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities – Action Guide 2.0 (National Quality Forum. June 2015)
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  The National Quality Strategy (NQS) prioritizes community efforts and interventions to improve social, economic, and environmental factors that impact health. Under contract with HHS, the National Quality Forum, using a multi-stakeholder, collaborative process, is developing a common framework that offers practical guidance for improving population health at the community level. The Action Guide handbook, intended for use by professionals of all disciplines and working at the local, regional, state, and national levels suggests ten elements important for building or refining initiatives to improve population health.
• Working Together, Moving Ahead: A Manual to Support Effective Community Health Coalitions (Shoshanna Sofaer, Dr.P.H. School of Public Affairs, Baruch College. 2001)
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  This report was one of several products of a multiyear assessment and formal evaluation of statewide tobacco control coalitions funded by the Robert Wood Johnson Foundation through its SmokeLess States Initiative. The manual aims to provide insight about the nature and development of community coalitions, and related structures and processes, while providing a practical guidebook for those using coalitions in their work.
• A Standard Framework for Levels of Integrated Healthcare: (SAMHSA-HRSA Center for Integrated Health Solutions. March 2013)
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  This issue brief reviews levels of integrated healthcare and proposes a functional standard framework for classifying sites according to these levels. The overarching framework has three main categories – coordinated, co-located, and integrated care –  and there are two levels of degree within each category. As depicted in the table, this framework is designed to help organizations implementing integration to evaluate their degree of integration across several levels and to determine what next steps they may want to take to enhance their integration initiatives.
• Integrated Practice Assessment Tool (IPAT) (Colorado Access, ValueOptions, Axis Health System. 2014)
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  The IPAT assessment tool is based on the issue brief, A Standard Framework for Levels of Integrated Healthcare. In contrast to other tools, it utilizes a decision tree model through a series of yes/no questions cascades to determine the level of healthcare integration and situate practices on the continuum identified in the brief.

Policy
Local, state and federal health laws and regulations may help support population health by assuring access to health care and needed services, strengthening the economic health of communities, and encouraging collaboration among different health related organizations, and supporting expanded roles for health care professionals.

• Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Brief Series (2008-present)
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  The Geiger Gibson RCHN Community Health Foundation Research Collaborative is a unique, comprehensive, multi-faceted academic and research initiative focused on community health centers. The Collaborative’s academic home is the Department of Health Policy and Management at Milken Institute School of Public Health, the George Washington University, the only school of public health in the nation’s capital. The Collaborative has produced more than four dozen white papers and special reports, as well as an extensive body of significant peer reviewed literature addressing medical underservice, health disparities and the role of community health centers in America’s safety net.
• The Economic and Employment Consequences of Repealing Federal Health Reform: A Fifty State Analysis. (Milken Institute School of Public Health, the George Washington University. January 2017)
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  This report by Dr. Leighton Ku and colleagues in the Department of Health Policy and Management at Milken Institute SPH finds that repeal of the ACA could lead to significant economic disruption and substantial job losses in every state. In 2019 alone, 2.6 million people could lose their jobs. These losses could rise to nearly 3 million positions in health care and other sectors by the year 2021. Research funded by the Commonwealth Fund, the Geiger Gibson RCHN Community Health Foundation Research Collaborative and Milken Institute School of Public Health, George Washington University.
• Repealing Federal Health Reform: Economic and Employment Consequences for States (The Commonwealth Fund. January 2017)
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  Issue brief to determine the state-by-state effect of repeal on employment and economic activity using a multistate economic forecasting model to quantify the effects of the federal spending cuts.
• Related Interactive Map: The Impact of the American Health Care Act on Employment (The Commonwealth Fund. 2017)

STEPS TO POPULATION HEALTH

• Screening, Brief Interventions, and Referral to Treatment (SBIRT)
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  SBIRT is an evidence-based practice to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.  The SBIRT model is intended to respond to Institute of Medicine recommendations calling for community-based screening for health risk behaviors, including substance abuse, and consists of three main components focused on: screening and assessment by a healthcare professional using standardized tools; brief direct interventions; and appropriate referrals for additional treatment.An overview of SBIRT is available via the SAMHSA- HRSA Center for Integrated Health Solutions http://www.integration.samhsa.gov/clinical-practice/SBIRT. Additional resources, reimbursement and financing information are available at: www.sbirttraining.com.
• The Patient Health Questionnaire (PHQ-9)
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  The Patient Health Questionnaire (PHQ-9) is a multi-purpose, self-administered questionnaire used for screening, diagnosing, monitoring, and measuring the severity of depression.  The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV (Diagnostic and Statistical Manual Fourth Edition).  (© 1999 Pfizer Inc.) 
• Short Form Health Survey SF-20

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  The 20-Item Short Form Health Survey (SF-20) was developed for the Medical Outcomes Study (MOS), a multi-year study of patients with chronic conditions, to describe mental and physical health status of adults, and to measure the outcomes of health care service. The domains addressed are physical functioning, role functioning, social functioning, mental health, and current health perceptions.
• Quality Payment Program: Patient Relationship Categories and Codes (Centers for Medicare & Medicaid Services, February 2018)
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  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required the development of patient relationship categories and related codes. Specifically, the patient relationship categories are intended to define and distinguish the relationship and responsibility of a clinician with a patient at the time of furnishing an item or service, facilitate the attribution of patients and episodes to one or more clinicians, and allow clinicians to self-identify their patient relationships. The voluntary reporting period began January 1, 2018. This slide set was presented at the CMS Patient Relationship Categories and Codes webinar, held February 21, 2018, which provided an overview of the coding scheme and examples for implementation. Also available on the CMS site are MACRA Patient Relationship Categories and Codes Frequently Asked Questions (as of May 2018).

Patient Engagement
Successful population health management, at the patient or the community levels, requires that individuals have the capacity to understand and participate in improving their health and preserving their wellness.

• Patient Engagement in Redesigning Care Toolkit – Version 2.0 (Davis S, Gaines ME, Pandhi N. Center for Patient Partnerships, UW Health, Primary Care Academics Transforming Healthcare, and UW Health Innovation Program; 2017)
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  Engaging patients in healthcare quality improvement and system redesign has become increasingly recognized as a key component of redesigning the US health care system to support patient-centered, high-quality primary care. This toolkit is intended for hospital and clinic directors, managers, clinicians, and researchers who are interested in the framework and tools for engaging patients as partners in health system quality improvement and change initiatives. This toolkit offers a high-level overview on patient engagement, worksheets that provide a step-by-step process to engage patients in Quality Improvement activities, and additional resources and tools to guide the work.
• Working With Patients and Families as Advisors (Agency for Healthcare Research and Quality. June 2013)
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  This handbook provides an overview of and rationale for how hospitals can work with patients and family members as advisors at the organizational level, outlines five steps for putting the strategy into place, and includes tools and specific suggestions for how to work with patient and family advisors.
• Quitting Smoking is Hard, But You Can Do It! (Charles B. Wang Community Health Center. 2016)
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  A Chinese/English bi-lingual video on the health risks of smoking and second-hand smoke.

Health Information Technology and Data Analytics
To support informed population health-oriented decision making at the practice and organizational levels, timely and accurate data, actionable information and a capacity to analyze and share it are essential.  

• Natural Language Processing (NLP) and Auto-Indexing in Healthcare (RCHN CHF. July 2016)
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  A brief prepared by Dr. David Hartzband, RCHN CHF Director of Technology Research, on the use of auto-indexing and NLP in health care applications and their value to community health centers.
• Understanding Data as an Asset – It’s a Necessity, Not a Luxury (Community Health Forum. Summer/Fall 2016)
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  Article by Dr. David Hartzband and Dr. Feygele Jacobs outlines the importance of data awareness and strong information management capacity in a rapidly transforming health system.
• Deployment of Analytics into the Healthcare Safety Net: Lessons Learned (Online Journal of Public Health Informatics. 2016)
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  This article by Dr. David Hartzband and Dr. Feygele Jacobs summarizes lessons learned from a multi-site initiative to evaluate health center data accuracy, reliability and completeness, and offers recommendations aimed at helping health centers answer two strategic questions: 1) How good are your data? and 2) How good are your systems?
• Compendium of Resources for Standardized Demographic and Language Data Collection (Centers for Medicare & Medicaid Services, March 2017)
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  This collection summarizes available resources related to uniform data collection standards to assist in identifying racial and ethnic health disparities, understanding the causes and correlates of disparities, monitoring progress in reducing them. It provides an overview of minimum standards for data collection as outlined by the U.S. Department of Health and Human Services, best practices for the implementation of standardized data collection by health care organization, and related training tools. The resources in this collection are grouped by race, ethnicity, and language (REaL) and disability categories as well as by resource type. Collecting standardized patient demographic and language data across health care systems is an important step toward improving population health, and the resources in this guide can help HCOs navigate that process.

PROCESS OUTCOMES

Person-Centered Care Design and Processes
In order to improve population health outcomes, the way care is delivered and the experience it creates for patients and families must be assessed and often transformed to achieve improvement.

• Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit (Cambridge Health Alliance)
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  This implementation guide and toolkit provides a framework for implementing a team-based model of care within a primary care setting. This resource offers a step-by-step guide to building effective care teams, beginning with the definition of goals and objectives, and ending with how to share lessons learned with other care teams on-site and at other health centers. It is guided by lessons learned from teams going through patient-centered medical home (PCMH) transformation in the Safety Net Medical Home Initiative, the Massachusetts Patient-Centered Medical Home Initiative and in the Robert Wood Johnson Pursuing Perfection program.
• Organized, Evidence-Based Care: Behavioral Health Integration – Implementation Guide Supplement (Safety Net Medical Home Initiative. October 2014)
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  The Safety Net Medical Home Initiative, launched in 2008 by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute, was a five-year national Patient-Centered Medical Home (PCMH) demonstration to help 65 primary care safety net sites become high-performing medical homes and improve quality, efficiency and patient experience. This implementation guide provides guidance and tools to help practices develop an implementation plan for integrated primary and behavioral health care.  
• Continuous and Team-Based Healing Relationships – Improving Patient Care Through Teams (Safety Net Medical Home Initiative. May 2013)
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  The Safety Net Medical Home Initiative, launched in 2008 by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute, was a five-year national Patient-Centered Medical Home (PCMH) demonstration to help 65 primary care safety net sites become high-performing medical homes and improve quality, efficiency and patient experience. This implementation guide addresses why care teams are important for improving patient care and ways to build an effective care team that meet patients’ needs and expectations.
• New Models of Primary Care Workforce and Financing (Agency for Healthcare Research and Quality [AHRQ]. October 2016)
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  A case study by AHRQ of pharmacy and primary care integration at Fairview Health Services in CT.
• Integration of collaborative medication therapy management in a safety net patient-centered medical home (Journal of the American Pharmacists Association. March/April 2011)
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  This article describes the integration of collaborative of medication therapy management (CMTM) in a community health center that serves people experiencing homelessness. 
• Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis (The Commonwealth Fund. October 2015)
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  This brief analyzes experts’ reviews of evidence about care models designed to improve outcomes and reduce costs for patients with complex needs.
• Advancing Quality Family Planning Practices: A Guide for Health Centers (The National Association of Community Health Centers. April 2017)
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  This resource is designed to support health centers in their efforts to improve access to high quality and comprehensive family planning services. The Guide highlights requirements and considerations for health centers interested in improving their provision of quality family planning and reproductive health services, including becoming a Title X grantee or sub-recipient. The Guide also summarizes various models to collaborate with existing family planning providers in order to leverage the organizations’ respective strengths, ranging from referral relationships to corporate consolidation.  The Office of Population Affairs and the Centers for Disease Control and Prevention within the Department of Health and Human Services funded the Guide development. 
• Asthma Community Network – Communities in Action
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  The Merck Childhood Asthma Network, Inc. (MCAN) and EPA have collected and cataloged implementation and evaluation tools, resources, outcomes and best practices from MCAN’s programs on the Network. This includes the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) training modules, developed and supported by MCAN in conjunction with the RCHN Community Health Foundation, and implementation guide along with materials documenting MCAN’s groundbreaking work in asthma disparities and care management.
• Effectiveness of Evidence-Based Asthma Interventions (Pediatrics. May 2017)
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  Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial enrolling children with moderate to severe asthma in 3 interventions and 3 geographically/capacity-matched control sites located in high-risk, low-income communities in Arizona, Michigan, and Puerto Rico community health centers. Merck Childhood Asthma Network (MCAN) and RCHN Community Health Foundation supported this initiative.
• Key Levers for Advancing Physical-Behavioral Health Care Integration at the Practice Level through Integrated Medicaid Managed Care [Infographic] (Center for Health Care Strategies, Inc. July 2019)
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  Integration of physical and behavioral health services has the potential to improve health outcomes and reduce costs for individuals with behavioral health care needs. This infographic, which summarizes recommendations from the brief, “Exploring the Impact of Integrated Medicaid Managed Care on Practice-Level Integration of Physical and Behavioral Health,” was produced with support from Blue Shield of California Foundation and the California Health Care Foundation. Based on the experiences of providers in three states — Arizona, New York, and Washington — that recently transitioned to integrated managed care,  it examines three key levers for advancing integrated care, and shares recommendations for states, health plans, and providers seeking to partner to advance greater physical-behavioral health integration.

Related resource: Core Competencies for Integrated Behavioral Health and Primary Care (SAMHSA-HRSA Center for Integrated Health Solutions, January 2014) in Quality Improvement.

Additional web resources:

• Academy for Integrating Behavioral Health and Primary Care
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  – The Academy for Integrating Behavioral Health and Primary Care organizes the knowledge base, research, and expert insight on why and how to integrate effectively on a meaningful scale. The Academy Web Portal offers definitions, measures, strategies, lessons learned, and other practical wisdom for quick application to the field of integration.
• Patient Centered Primary Care Collaborative (PCPCC)
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  – The PCPCC is a coalition of more than 1,000 organizations and individuals that works to develop and advance an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH) model.
• National Resource Center for Patient/Family-Centered Medical Home (formerly the National Center for Medical Home Implementation)
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  – This website provides tools, resources, state-specific information for pediatric practices interested in learning more about the pediatric medical home.

• Safety Net Medical Home Initiative
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  – The Safety Net Medical Home Initiative was a 5-year national Patient-Centered Medical Home (PCMH) demonstration launched in 2008 to help 65 primary care safety net sites become high-performing medical homes and improve quality, efficiency and patient experience. The initiative created a framework for PCMH transformation and published a library of resources and tools, which are available on this website, to help practices implement the PCMH Model of Care.

Quality Improvement
Population health improvement strategies are both essential to practice transformation, and driven by the need to transform care and improve quality while strengthening capacity for sustainability.

Community-Level Population Health Management
Population health management encompasses initiatives focused on improving outcomes for a defined population in a community or geographic region, rather than those strictly limited to health center or facility-specific patients and families. These resources describe such community-focused, equity-oriented efforts and provide tools, ideas and strategies that may be adapted to address local conditions.