As part of the Foundation’s signature Population Health initiative, RCHN CHF collaborated with project grantees to co-design a learning collaborative and to share information among grantees and their partners. Learning sessions focused on approaches to deepen and strengthen health center operational and clinical capacity, develop partnerships, and enhance the potential for sustainability. Through regular learning community interactions, participants shared their experience in implementing a diverse set of interventions and learned from each other and expert faculty. The resources and tools identified throughout the learning collaborative may be useful to other health center organizations in their journey to improve population health and are presented here in the spirit of collaboration and expanding general knowledge. The resources are grouped to reflect major categories – Environmental Drivers, Steps to Population Health, and Process Outcomes – that are relevant for all health center population health management work regardless of the target population identified for interventions.
This page will be updated periodically as new resources are added.
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)
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)
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)
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.
- Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation (Rosy Chang Weir, Michelle Proser, Michelle Jester, Vivian Li, Carlyn M. Hood-Ronick, Deborah Gurewich. Journal of Health Care for the Poor and Underserved, Volume 31, Number 2, May 2020, pp. 1018-1035. DOI: https://doi.org/10.1353/hpu.2020.0075)
This cross-sectional study examines patients’ needs related to social and community risk factors (Social Determinants of Heath- SDH) from the implementation, across three pilot cohorts, of the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) SDH risk assessment and action protocol. PRAPARE is a standardized, evidence-based SDH assessment tool that bridges social risk assessments and clinical indicators, and was developed through a consensus process by the National Association of Community Health Centers (NACHC), the Association of Asian Pacific Community Health Organizations (AAPCHO), the Oregon Primary Care Association (OPCA), and the Institute for Alternative Future. This analysis is the first ever conducted with standardized PRAPARE SDH data to explore the socioeconomic profiles of large populations nationally and advance our understanding of SDH prevalence among underserved populations. The authors find that nationally, patients faced 7.2 social risks, on average, with the most common risks across all three cohorts identified as limited English proficiency, education at less than the high school level, lack of insurance, high to medium-high stress, and unemployment. The findings point to data that can inform social interventions and upstream transformation to improve health equity for underserved populations.
- Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)
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)
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)
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).
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.
- Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19 (Horwitz, L. I., Chang, C., Arcilla, H. N., & Knickman, J. R. (2020). Health Affairs, 39(2), 192–198. doi: 10.1377/hlthaff.2019.01246).
The authors investigate major new investments by U.S. health systems that directly target social determinants or community health, the characteristics of those systems, and how such investments are being allocated across social sectors. For the period January 1, 2017, to November 30, 2019, they identified 57 (9.1 percent) of the 626 health systems as having made specific commitments to 78 distinct programs, at 917 hospitals. In total, these systems allocated $2.5 billion to toward directly addressing social determinants of health. Investments included housing-focused interventions ($1.6 billion in fifty-two programs), employment (twenty-eight programs, $1.1 billion), education (fourteen programs, $476.4 million), food security (twenty-five programs, $294.2 million), social and community context (thirteen programs, $253.1 million), and transportation (six programs, $32 million). Overall, the study found that health systems are making sizable investments in social determinants of health, particularly in the areas of housing and employment.
- Impact of Social Factors on Hospital Readmissions at Massachusetts’ Two Largest Safety Net Hospitals After State Health Reform (Danny McCormick, Srini Rao, Nancy Kressin, Rich Balaban, Leah Zallman, Journal of Healthcare for the Poor and Underserved, 2019;30(4):1467-1485 November 2019 doi: 10.1353/hpu.2019.0092) (Abstract only).
The authors of this study conducted a prospective cohort analysis of 713 non-elderly adults at two of Massachusetts’ largest safety net hospitals (SNHs) eight years after Massachusetts’ health reforms. The study found that public insurance, White race/ethnicity, being unemployed, being unstably housed, having an alcohol-related index admission, and having a substance use-related index admission were associated with readmissions at 90 days. At 30 days, public insurance, worry about safety or condition of housing, and having an alcohol-related index admission were associated with readmissions. These findings suggest that accounting for social factors in readmission adjustment schemes used by payers may be important for ensuring payment equity.
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.
- Partnership Assessment Tool for Health (Developed by Partnership for Healthy Outcomes, 2017)
The objective of the PATH is to help partnering organizations work together more effectively to maximize the impact of their partnership, and is intended for community-based organizations (CBOs) that provide human services and healthcare organizations currently engaged in a partnership. For the purposes of this tool, partnership is defined as a structured arrangement between a healthcare organization and nonprofit or for-profit community-based organization (e.g. housing organization, workforce development agency, food bank, early childhood education provider) to provide services to low-income and/or vulnerable populations. The tool provides a structured format to help organizations assess progress toward benchmarks characteristic of effective partnerships, identify areas for further development, and guide strategic conversation between partners. The Partnership Assessment Tool for Health (PATH) was developed by the Partnership for Health Outcomes, a year-long project launched in 2017 with support from the Robert Wood Johnson Foundation. Project partners included the Nonprofit Finance Fund (NFF), the Center for Health Care Strategies (CHCS), and the Alliance for Strong Families and Communities (Alliance).
- Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities – Action Guide 2.0 (National Quality Forum. June 2015)
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)
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)
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)
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)
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)
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)
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)
Payment
The ongoing operation and sustainability of population health strategies rests upon both strong business models and appropriate reimbursement. Community health centers represent one of the principal sources for care for the nation’s Medicaid population, and an understanding of the enduring and interdependent relationship with Medicaid is essential, as is appreciation of the opportunities for transformation through payment reform.
- The Quiet War on Medicaid (New York Times. December 25, 2016)
A New York Times op-ed by Gene Sperling, former director of the National Economic Council, urges lawmakers to keep vigilant against the potentially devastating effects of dismantling Medicaid.
- America’s concern for the poor is about to be tested (Washington Post. December 26, 2016)
In this Washington Post op-ed, Robert Greenstein discusses the grave threats faced by America’s poor if safety net and domestic programs are cut.
- Obamacare Boosted Community Health Centers’ Reach. Now What? (Kaiser Health News. January 9, 2017)
This article summarizes two Health Affairs studies on the impact of Medicaid expansion on community health centers.
Medicaid Expansion And Grant Funding Increases Helped Improve Community Health Center Capacity examines the effects of both ACA Medicaid expansion and changes in CHC grant funding levels on the centers’ numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015; it documents increased capacity in expansion states, with more visits overall and more mental health visits/ mental health access.
At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care shows that Medicaid expansion was associated with large increases in Medicaid coverage and corresponding declines in uninsurance rates. Medicaid expansion was also associated with improved quality at CHCs on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control.
- How Medicaid and Other Public Policies Affect Use of Tobacco Cessation Therapy, United States, 2010–2014 (Preventing Chronic Disease. October 27, 2016)
This article by Dr. Leighton Ku and colleagues assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers.
- The Value Transformation Framework: An Approach to Value-Based Care in Federally Qualified Health Centers (Modica, C. (2020). Journal for Healthcare Quality. doi: 10.1097/JHQ.0000000000000239) (Abstract only)
The Value Transformation Framework was developed to guide health center systems change toward high value care. It identifies 15 change areas across three domains: infrastructure, care delivery, and people and summarizes evidence-based action steps within the change areas. This article describes the development process and defines the resulting conceptual framework. The framework was developed between 2016 and 2018 at the National Association of Community Health Center’s (NACHC) Quality Center with support from the Centers for Disease Control and Prevention (CDC).
STEPS TO POPULATION HEALTH
Patient Identification, Assessment, Stratification
Identifying the target population, assessing need, and stratifying the community based on risk are essential to developing effective population health improvement strategies. This effort requires both solid data, and the use of patient- and community-focused decision support tools.
- Screening, Brief Interventions, and Referral to Treatment (SBIRT)
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)
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.)
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Short Form Health Survey SF-20
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)
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).
Related resources:
Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) and
Social Determinants of Health Needs Assessment Survey and Staff Assessment (Colorado Community Health Network. 2015) in
Social Determinants of Health (SDoH).
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)
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)
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)
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.
- Information Technology and Data in Healthcare: Using and Understanding Data (David Hartzband, David. HIMSS Book Series. CRC Press, Taylor and Francis Group. 2020)
One of the long-standing challenges in healthcare informatics has been the ability to deal with the sheer variety and volume of disparate healthcare data and the increasing need to derive both veracity and value. The author, Director of Technology Research at the RCHN Community Health Foundation, provides an explanation based on epistemology (theory of knowledge) of what data actually is, what we can know about it, and how we can reason with it. The culture of data, where it fits into healthcare, and data quality are also addressed.
The author provides a description of how healthcare data analysis is changing in the era of abundant data. The book also describes how healthcare information infrastructure needs to change in order to meet current and future needs, and concludes with thoughts on the evolution of the role and use of data and information, and the application of artificial intelligence and machine learning going into the future.
- Natural Language Processing (NLP) and Auto-Indexing in Healthcare (RCHN CHF. July 2016)
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)
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 (Hartzband, D., & Jacobs, F. (2016). Online Journal of Public Health Informatics, 8(3): e203. doi: 10.5210/ojphi.v8i3.7000)
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)
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.
- Integrating Behavioral Health into Medicaid Managed Care: Design and Implementation Lessons from State Innovators (Center for Health Care Strategies, Inc., Michelle Herman Soper, April 2016)
This brief provides insights from Medicaid officials and health plan representatives in five states – Arizona, Florida, Kansas, New York and Texas – that are pursuing innovative approaches to integrate behavioral health services within a comprehensive managed care arrangement. It explores key lessons to guide state integration efforts designed to improve outcomes and reduce costs. It reviews practical program design and implementation considerations to inform additional states’ efforts to “carve-in” behavioral health into existing managed care arrangements or provide an alternative integrated arrangement. These new approaches to integration are particularly valuable as states expand Medicaid and recognize the benefits of Medicaid coverage for individuals with behavioral health needs. The brief was developed by the Center for Health Care Strategies, Inc. with support from Kaiser Permanente Community Benefit.
- Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit (Cambridge Health Alliance)
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.
- Building Integrated Care: Lessons from the UK and elsewhere (Naomi Fulop and Alice Mowlem, King’s College London. Nigel Edwards, NHS Confederation, November, 2008)
This report reviews the dimension of integrated systems, offers a conceptual framework for understanding integrated systems, provides evidence on vertical integration using both U.K. and U.S. examples, and addresses lessons for practice and policy, including pitfalls to be avoided in planning for effective integrated delivery systems. Prepared by the National Health Service (NHS) Confederation, a U.K.-based member organization representing entities that plan, commission and provide NHS services, Building Integrated Care.
- Organized, Evidence-Based Care: Behavioral Health Integration – Implementation Guide Supplement (Safety Net Medical Home Initiative. October 2014)
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)
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)
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 (Moczygemba, L. R., Goode, J. V., Gatewood, S. B., Osborn, R. D., Alexander, A. J., Kennedy, A. K., Stevens, L. P., & Matzke, G. R. (2011). Journal of the American Pharmacists Association: JAPhA, 51(2), 167–172. doi: 10.1331/JAPhA.2011.10191)
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)
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)
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
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)
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)
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
– 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)
– 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)
– 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
– 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.
- The Core Quality Measures Collaborative
The Core Quality Measures Collaborative is an effort convened by The Centers for Medicare & Medicaid Services (CMS), in conjunction with collaborators representing insurers, purchasers, physician and other health care provider organizations and consumers, to develop consensus measures that could be harmonized across public and commercial payers. Reviewing these measures will help health centers decide on the best metrics for their population health quality improvement efforts. The core quality measures include a measurement set with an emphasis on primary care: Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care. Seven additional measurement sets, some of which also include primary care related metrics, are: Cardiology; Gastroenterology; HIV and Hepatitis C; Medical Oncology; Obstetrics and Gynecology; Orthopedics; and Pediatrics.CMS and America’s Health Plans (AHIP) released the consensus core set (V 1.0) for ACO and PCMH/ Primary Care Measures in February 2016. Current measures sets are available at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html
- The Institute for Healthcare Improvement (IHI) Improvement Capability Self-Assessment Tool (2010)
This tool, originally developed by IHI for hospitals participating in the Health Disparities Collaboratives (a national quality improvement initiative developed by the Bureau of Primary Health Care and the IHI, operational 1999-2006), assesses organizational capability in several domains that are associated with overall outcomes-improvement success: 1) Leadership for Improvement; 2) Results; 3) Resources; 4) Workforce and Human Resources; 5) Data Infrastructure and Management; and 6) Improvement Knowledge and Competence.
- Core Competencies for Integrated Behavioral Health and Primary Care (SAMHSA-HRSA Center for Integrated Health Solutions, January 2014)
This set of core competencies was created under the auspices of the Center for Integrated Health Solutions by the Annapolis Coalition of Behavioral Health Workforce and addresses integrated practice relevant to behavioral health and primary care providers. It is intended to serve as a resource of common competencies for provider organizations as they shape job descriptions, orientation programs, supervision, and performance reviews for staff delivering integrated care. It is also a resource for educators as they shape curricula and training programs on integrated care.
- Guide to Reducing Disparities in Readmissions (Centers for Medicare & Medicaid Services, revised August, 2018)
This guide provides an overview of key issues related to readmissions for racially and ethnically diverse Medicare beneficiaries, as well as useful resources and strategies for hospital leaders to take action to address readmissions. Developed for the CMS Office of Minority Health as part of the CMS Equity Plan for Improving Quality in Medicare, it is designed to assist hospital leaders and stakeholders focused on quality, safety, and care redesign. This guide was prepared by the Disparities Solutions Center at Massachusetts General Hospital in partnership with NORC at the University of Chicago, and is aligned with the goals of the CMS Partnership for Patients, focused on improving care transitions, reducing 30-day hospital readmissions, making care safer, and reducing costs (
https://partnershipforpatients.cms.gov/).
- Health Care Hotspotting — A Randomized, Controlled Trial (Finkelstein, A., Zhou, A., Taubman, S., & Doyle, J. (2020). New England Journal of Medicine, 382(2), 152–162. doi: 10.1056/nejmsa1906848) (Abstract only)
In this article, authors describe the results of a randomized, controlled trial which analyzes the “hotspotting” program created by the Camden Coalition of Healthcare Providers (Coalition). As part of the program, patients received coordinated outpatient care and referrals to social services from nurses, social workers, and community health workers in the months after hospital discharge. To evaluate the impact of the program, authors of the study randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition’s care-transition program or to usual care. The primary outcome in both groups was hospital readmission within 180 days after discharge.
- Understanding A3 Thinking (Prentice Hall, Durward K. Sobek II, Art Smalley, 2015)
A3 problem solving is a structured problem-solving and continuous-improvement approach. It provides a simple and structured procedure that helps a problem solver think systematically through a problem, its root cause or causes and possible solutions, and plan an experiment for proposed solutions. The A3 tool can help community health centers and other HCOs identify and resolve operational, programmatic, and clinical inefficiencies in order to improve overall value.
- Developing Lean Leaders at all Levels: A Practical Guide (Lean Leadership Institute Publications, Jeffrey Liker, 2015)
The Lean Leadership Development Model (LLDM) presented in this book aligns with accepted principles of operational excellence. The book expands significantly on the elements of Lean, by structuring lean concepts in a more specific way that can be operationalized by practitioners.
Additional Item of Interest re: Lean: Creating a Lean Culture: Tools for Sustaining Lean Conversions (Routledge, David Mann, 2014)
Related resources: 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) in Patient Engagement, Compendium of Resources for Standardized Demographic and Language Data Collection (Centers for Medicare & Medicaid Services, March 2017) in Health Information Technology and Data Analytics, The Value Transformation Framework: An Approach to Value-Based Care in Federally Qualified Health (Modica, Cheryl, Journal of Healthcare Quality January 30, 2020 doi: 10.1097/JHQ.0000000000000239) in Payment, and Impact of Social Factors on Hospital Readmissions at Massachusetts’ Two Largest Safety Net Hospitals After State Health Reform (Danny McCormick, Srini Rao, Nancy Kressin, Rich Balaban, Leah Zallman, Journal of Healthcare for the Poor and Underserved, 2019;30(4):1467-1485 November 2019 doi: 10.1353/hpu.2019.0092) in Social Determinants of Health (SDoH)
The objective of evaluation is to facilitate learning that will help inform modifications or improvements to a given strategy, initiative or program. Evaluation can be used to document a program’s effectiveness and impact by assessing quality, cost, and outcomes or to identify areas for improvement by gathering information throughout program implementation to determine if program objectives are being met. Evaluation strategies should be identified early, during the program planning phase, to clarify and guide implementation.
- Developing an Effective Evaluation Plan (Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Division of Nutrition, Physical Activity and Obesity. 2011)
The purpose of this workbook is to help public health program managers, administrators, and evaluators develop an effective evaluation plan in the context of the planning process. Developed by the Centers for Disease Control (CDC) as part of a series of technical assistance workbooks, it applies the CDC Framework for Program Evaluation in Public Health
(www.cdc.gov/eval), which lays out a six-step process for the decisions and activities involved in conducting an evaluation. These include: engaging stakeholders; describing the program; focusing the evaluation design; gathering credible evidence; justifying conclusions; ensuring use; and sharing lessons learned. It is intended to offer guidance to organizations and programs developing an evaluation plan and is designed to be used as a capacity-building resource, in conjunction with other materials.
- The Step-by-Step Guide to Evaluation: How to Become Savvy Evaluation Consumers (W.K. Kellogg Foundation, November 2017)
This handbook is designed to demystify evaluation and help organizations get the most out of the evaluation process. It describes the various evaluation types, methodologies and approaches, provides a brief overview of the overall evaluation process and its stages, outlines key considerations for planning an evaluation, and offers key considerations for summarizing and communicating evaluation findings. This Guide is a successor to the original Evaluation Handbook first published in 1998, updated in 2004 and revised 2014.
- Using Logic Models to Bring Together Planning, Evaluation, and Action: Logic Model Development Guide (W.K. Kellogg Foundation, 1998, Updated 2004)
A logic model is a picture of how your organization does its work, documenting, in text and graphic form, the theory and assumptions underlying the program. A program logic model links the assumptions underlying the program to program activities/processes and intended short- and long-term outcomes. This guide was developed to provide an orientation to the principles of logical modeling and offer practical assistance to nonprofits engaged in initiating and completing outcome-oriented evaluation of projects. It was prepared as a companion publication to the original Evaluation Handbook. The Step By Step Guide to Evaluation, and updated volume to the Handbook, also offers a chapter on logic modeling.
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.
