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Quick Finds: Social Determinants of Health

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Introduction. Use this page to quickly find all resources from the Clearinghouse database on special and vulnerable populations.

Background. Social Determinants of Health are the social conditions that influence individual and community health. Those determinants include housing, poverty, nutrition, education and family stability.

You can learn what the Social Determinants of Health Academy is doing in this area.

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Results for: Topic Area = Social Determinants of Health

Displaying all 236 records.

The COVID-19 Pandemic Resources and Information: Spanish and English (2020). Resource Type: Other. Description: We at Migrant Clinicians Network have a priority to support both clinicians and the vulnerable patients they serve. MCN continually develops strategies and resources to support health centers, health departments, community groups, and clinicians as they reach out to communities that are often overlooked and give care to patients who might otherwise have nowhere to go. We remain highly concerned for the vulnerable populations that already encounter numerous barriers to health and to care. More Details...

COVID-19 Vaccine:  Tips from your Community Health Worker (2021). Resource Type: Publication. Description: COVID-19 vaccines are a critical tool to help stop the spread of disease and protect our communities. MHP Salud\'s Tips from your Community Health Worker resource for is designed for health workers supporting patients with Limited English Proficiency (LEP). The tips and resources aim to help health centers build vaccine confidence among the migrant and agricultural worker population and their families. More Details...

Bridging Patient Access: Best Practices for Community Health Workers (2021). Resource Type: Publication. Description: As telehealth services continue to bridge patient access to health services, it is important for health centers to focus on best practices that ensure excellent delivery of care. Thisguideincludeshelpful information about telehealth service delivery, tips for providing good virtual care, and how Community Health Workers(CHWs)can engage in telehealth. More Details...

National Diabetes Prevention Program: Final Summary 2021 (2021). Resource Type: Archived In-Person Training. Description: This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,350,000 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. More Details...

Module 1: Cultural and Self-Humility with Nationalities Services Center - Populations at Risk for HepB (2021). Resource Type: Archived Webinar. Description: Ariel MacNeill and Bianca Taipe from the Nationalities Services Center, whose mission focuses on welcoming immigrants and refugees and connecting them to services in Philadelphia, PA, will discuss cultural and self-humility as it relates to providing health care and social services to people coming from different cultural identities. The presenters will also review trauma-informed practice and barriers that different populations face in accessing health care, as well as resources to address those barriers. More Details...

Community Health Workers and Peer Specialists: Key Roles in Addressing Diabetes Control Before and During COVID-19 Health Pandemic (2021). Resource Type: Publication. Description: This publication showcases the important role of front-line CHW/Peer Specialists in maintaining connections with the community for diabetes control, especially in the time of a health pandemic. More Details...

Population Management Approach to Reaching Key Populations as they Become Eligible (2021). Resource Type: Archived Webinar. Description: To meet the demand for knowledge on COVID-19 vaccines, CHCI and its Weitzman Institute is moving back to weekly COVID-19 national webinar sessions! More Details...

Health Policy Bulletin Winter 2021: Policies in Action to Promote Emergency Preparedness (2021). Resource Type: Publication. Description: Farmworker Justice's Health Policy Bulletin is a summary of policy, program, and research developments that affect farmworker health and access to health care. This issue focuses on emergency preparedness in agricultural worker communities. More Details...

Strengthening Partnerships for Better Health Outcomes During COVID-19 (2021). Resource Type: Publication. Description: For the first time in recent memory, homelessness has been acknowledged as a public health crisis, one that community health centers of all kinds are beginning to confront. These case studies profile health centers that partnered with homeless services organizations to coordinate on COVID-19 services for people without homes. More Details...

COVID-19 Homeless System Response: Vaccine Planning and Distribution (2021). Resource Type: Publication. Description: Vaccines are a vital, lifesaving tool that prevent illness and death. Vaccines have greatly reduced or eliminated many infectious diseases that once routinely killed or harmed adults and children, particularly those living in poverty. It is essential that households experiencing homelessness have access to the COVID-19 vaccine. Many states and counties around the country have prioritized vaccine access both for homeless service providers and individuals experiencing homelessness. More Details...

Homeless Mortality and the Impact of COVID-19 (2021). Resource Type: Archived Webinar. Description: This webinar gave an overview of the new Homeless Mortality Data Toolkit, featuring two communities who conduct a thorough review of homeless mortality, including reflections on the impact of COVID-19 on untimely deaths. Determining leading cause of death is a crucial part of health centers\' needs assessment requirements; for any health center serving people without homes, the strategies shared in this discussion should be central. More Details...

Understanding Social Determinants of Health: Back to the Basics on the factors that impact health outcomes (2020). Resource Type: Archived Webinar. Description: This webinar highlights its not just the care received in the clinic. In reality the health outcomes are impacted by services throughout the community. Community partnerships are essential to leverage the resources to meet needs. More Details...

Physical Activity & Diabetes Prevention in the COVID-19 Landscape (2020). Resource Type: Archived Webinar. Description: In the context of COVID-19 traditional strategies to engage patients in diabetes control were curtailed. This webinar highlights the why and how for physical activity to address diabetes in these constrained economic times and the key roles of community partners. More Details...

Data Integration Best Practices for Health Centers & Homeless Services Publication: Health Center Focus Group Recommendations on Data Integration (2020). Resource Type: Publication. Description: Health centers use data and technology to improve health outcomes of patients, speed administrative processes, and collect patients’ health and housing histories. This report advances strategies for large and small health centers to match data with homeless service systems to identify and coordinate care for high utilizers of crisis care systems. More Details...

Breaking the Cycle of Integenerational Diabetes Webinar: Webinar highlights strategies to address diabetes impacting multi-generational families (2021). Resource Type: Archived Webinar. Description: This webinar highlights health center programs that reach into underserved communities to address diabetes care across generations More Details...

A Call for Reinforcements in Diabetes Care: Maximizing the Role of Non-Clinical Staff and Partners Publication: Issue brief and case studies highlightin promising practices for non-clinical staff with links to the community (2020). Resource Type: Publication. Description: Successful diabetes care for vulnerable populations demands a multi-prong approach and support from a range of community resources to address SDOH. This report outlines promising practices utilizing interdisciplinary teams and community resources can support consumers’ self-management and in-turn More Details...

Federal Activities and Approaches to Advance Social Determinants of Health Data Use and Interoperability in Support of Community Health Centers: HITEQ Highlights Webinar (2020). Resource Type: Archived Webinar. Description: View this HITEQ Center webinar, where the The Health and Human Services, Office of the National Coordinator for Health IT present on the current state of federal activities and standards based approaches for collecting, sharing, and using SDoH data with a focus on technical and policy considerations. The presentation describes available standards, tools, and initiatives for health center use and input. More Details...

Public Housing Primary Care (PHPC) COVID-19 Dashboard (2020). Resource Type: Publication. Description: This dashboard by NCHPH provides the latest COVID-19 statistics in Public Housing Primary Care (PHPC) Health Centers, including race and ethnicity data and additional resources. More Details...

Homeless Persons Mortality Toolkit (2020). Resource Type: Toolkit. Description: Homelessness is deadly. People without homes are more vulnerable to virtually every illness and injury and die, on average, 30 years earlier than housed people. As part of health centers' required periodic needs assessment, cause of death for people experiencing homelessness must be measured: this toolkit shows you how. More Details...

Telehealth Office Hours: Caring for Vulnerable Populations during COVD-19 Pandemic (2017). Resource Type: Archived Webinar. Description: This webinar features Care for the Homeless in New York City and the steps they have taken to train staff in order to streamline care virtually and to ensure care is accessible to all regardless of housing status. More Details...

Supporting Implementation of Smoking Cessation Programs in Public Housing Primary Care Settings: Learning Collaborative (20; Session 2 11). Resource Type: Archived Webinar. Description: During this learning collaborative health center staff learned about different aspects for implementation of smoking cessation programs. More Details...

Preparing Your Community for the Flu: Partnering with Health Providers to Prevent a Twindemic: Webinar (2020). Resource Type: Archived Webinar. Description: During this webinar, the Healthcare Resilience Working Group discussed the initiatives that are currently taking place at a national level to prepare health center communities for flu season 2020 and how partnerships with public housing agencies and health care providers to prevent a twindemic between flu and COVID-19 among vulnerable populations is important during these unprecedented times. In this session, various health promotion resources were shared as well other resources for patients to use to successfully locate a flu vaccine provider. More Details...

Diabetes and Seasonal Influenza (Flu) During COVID-19: Protect Yourself! (2020). Resource Type: Publication. Description: This infographic addresses the importance of influenza (flu) prevention among public housing residents with diabetes during the COVID-19 pandemic. More Details...

Culturally Competent Care: Learning Collaborative (20; Session 2 11). Resource Type: Other. Description: This is a learning collaborative series of 4 sessions where Health Center staff learned about standards for providing culturally and linguistically appropriate services (CLAS) to their patients. Slides and recordings for all sessions are available here as well as resources to facilitate the implementation of CLAS in health center settings. More Details...

Considerations for Serving Residents of Public Housing During Emergencies and Disasters: Staff and Patient Wellness (2020). Resource Type: Archived Webinar. Description: Join the National Nurse-Led Care Consortium and the National Center for Health in Public Housing for a one-hour webinar on staff and patient wellness during emergencies and disasters. This webinar will provide health center with guidance for developing tools and resources that enable health center staff and the patients they serve to navigate the practical and psychological after-effects of disaster events. More Details...

Uniform Data System Analysis of Agricultural Worker Patients & Household Members, 2019 (2020). Resource Type: Publication. Description: A brief visual overview of sociodemographic information about migratory and seasonal agricultural worker patients of Community & Migrant Health Centers. Based on the 2019 Uniform Data System More Details...

Two Sides of the Same Coin: Addressing Social Determinants of Health and Enabling Services Data Collection (2019). Resource Type: Archived Webinar. Description: As health centers are held accountable for cost containment and high quality of care under value-based pay arrangements, it is increasingly important for providers to document the social determinants of health (SDoH) barriers of their patients and what services they are providing (both clinical and non-clinical) in order to properly care for those complex patients. Some of these services are called enabling services (ES), defined as non-clinical services that aim to increase access to care and improve health outcomes. Standardized data collection on SDoH and ES are two sides of the same coin and provide the foundation for health centers to succeed in a value-based pay environment. This not only helps them address root causes of poor health, but also highlights the value of the health center model. More Details...

Telehealth for Supportive Housing Providers - CSH Three Part Telehealth Series: Guidance for Providers looking to adapt and are considering Billing for themselves (2020). Resource Type: Publication. Description: In the COVID19 environment technology can be used as a complement to face-to-face services, and also as a service on its own. Technology options can be especially useful for people with depression or suffering from distress, and when there are difficulties in physically meeting with tenants. More Details...

Telehealth Basics for Supportive Housing Providers and their Health Center Partners - CSH Three Part Telehealth Series: Guidance for Providers Looking to Support Residents Getting Connected to Telehealth (2020). Resource Type: Publication. Description: The public health emergency related to the COVID-19 pandemic has required the health care sector including Community Health Centers and supportive housing providers to work in new ways to support their service participants (i.e. health center patients who are also supportive housing tenants). This brief considers the basics regarding telehealth for collaborations between health centers and the supportive housing field to consider as they adapt to provide services in a manner that protects both the client and staff. More Details...

Supporting Tenants During COVID-19 Using Technology Based Strategies - CSH Three Part Telehealth Series: Tips for Using Technology to Support Tenants in Supportive Housing Tenants (2020). Resource Type: Publication. Description: In Telehealth, the Technology can be used as a complement to face-to-face services, and also as a service on its own. Technology options can be especially useful for people with depression or suffering from distress, and when there are difficulties in physically meeting with tenants. This guide highlights the steps recommended for establishing your telehealth technology, connecting with residents and compliance with requirements such a HIPAA. More Details...

Leveraging the Electronic Health Record to Link Health Center Patients with Medical-Legal Partnership Services (2020). Resource Type: Publication. Description: This issue brief provides concrete examples of how health centers in Iowa, Montana, and Texas are leveraging the EHR to complement their screening for the social determinants of health as well as to increase their capacity to deliver targeted MLP-related interventions. More Details...

Farmworker Health Network 2020 Key Resources for Agricultural Worker Health (2020). Resource Type: Publication. Description: The Farmworker Health Network (FHN) is comprised of six National Cooperative Agreements in migrant health funded through the US Department of Health and Human Services (HHS) to provide training and technical assistance to current and potential Migrant Health Center Programs. The FHN is committed to supporting the development of leadership within Community and Migrant Health Centers and increasing access to care for the farmworker population. More Details...

Enabling Services Data Collection: Documenting Health Center Interventions in a Value-Based Payment Environment (2020). Resource Type: Archived Webinar. Description: In collaboration with Health Outreach Partners (HOP), AAPCHO promoted the importance of documenting social determinants of health (SDoH) interventions to demonstrate the value and scope of health center enabling services (ES). AAPCHO and HOP was joined by the Community Health Care Association of New York State (CHCANYS) to highlight how state, regional, and national partners can leverage SDoH and ES data for Value-Based Payment (VBP). More Details...

Centering Equity in Health and Housing Partnerships in Times of Crisis and Beyond: Supporting front line health providers to understand and incorporate health equity in their policies, programs and delivery of health services. (2020). Resource Type: Publication. Description: This paper addresses how health centers, other health system providers, and housing partners can center considerations of equity in their shared work to address the needs of people most impacted by structural racism and its impact on health and social determinants of health, including Black people, people of color, and Indigenous people. More Details...

Flu LEAD (Linkages to End Access Disparities) Initiative 2020 Information: A Pilot Project to Increase Influenza Vaccination Coverage among HUD-Assisted Residents (2020). Resource Type: Publication. Description: This NCHPH informational page provides an overview, and resources about the Flu LEAD pilot project directed by the U.S Department of Housing and Urban Development (HUD and the Health Resources and Services Administration (HRSA) to increase influenza vaccination coverage among residents of Public Housing Agencies (PHAs). More Details...

EnVision Centers, Jobs Plus and Health Centers Interactive Map (2020). Resource Type: Interactive Map. Description: NCHPH recently launched a new interactive map. This map shows the location of Health Centers, Envision Centers and Jobs Plus sites. EnVision Centers are centralized hubs that provide people living in public housing with resources and support needed to excel. Jobs Plus Sites. The place-based Jobs Plus Initiative program addresses poverty among public housing residents by incentivizing and enabling employment. Health Centers interested in partnering with near Envision Centers and Jobs Plus sites, visit this NCHPH resource and hover over the organization you want to partner with. Contact information will then be displayed in the information box. More Details...

Bringing lawyers onto the health center care team to promote patient & community health: A planning, implementation and practice guide for building and sustaining a health center-based medical-legal partnership (2020). Resource Type: Publication. Description: The toolkit has four parts: 1. Outlines nine conversations that a health center team should have with its legal partners to plan for an MLP’s long-term success and to integrate it into the health center’s operations. 2. Is a deep dive into the specifics of how to develop screening, referral, and service delivery workflows. 3. Looks at how integrating legal services can support health center workforce development, with a particular focus on training. 4. Illustrates the types of projects MLPs can engage in to help your health center move upstream to address SDOH and health equity at a policy level. More Details...

Social Determinants of Health for Public Housing Residents: Access to Healthy Food (2020). Resource Type: Publication. Description: Using data and maps created by National Center for Health in Public Housing (NCHPH) and other national data sources, this publication is one in a series that identifies the prevalence of social factors and population health indicators that affect public housing residents. It is intended for non-clinical health center staff, decision makers, and public housing stakeholders. More Details...

Leveraging the electronic health record (EHR) to link health center patients with MLP services (2020). Resource Type: Publication. Description: This issue brief provides concrete examples of how health centers in Iowa, Montana, and Texas are leveraging the EHR to complement their screening for the social determinants of health as well as to increase their capacity to deliver targeted MLP-related interventions. More Details...

Fact Sheet: The role of medical-legal partnerships for socially vulnerable older adults. (2020). Resource Type: Fact Sheet. Description: This fact sheet looks at how integrating medical and legal services for older health center patients can help mitigate overlapping health and social challenges and begin to comprehensively address problems that directly impact a patient’s health and well-being. It examines how these partnerships work, and highlights two medical-legal partnership programs for seniors in San Francisco and Boston. More Details...

Bridging the Digital Divide: Using Technology to Improve Access to Health Care for Public Housing Residents (2020). Resource Type: Publication. Description: The purpose of this report is to outline the digital needs and challenges of public housing residents, the risks and benefits of using technology to improve patient care, and recommendations on how to prepare health centers and patients to optimize digital tools, improve access to care, and enhance efforts through partnerships to bridge the digital divide. More Details...

Delivering Telelegal Services During COVID-19 (2020). Resource Type: n.a.. Description: This town hall featured teams from Los Angeles, Montana, and Alaska who have experience delivering remote medical-legal partnership services in urban, rural, and frontier settings More Details...

Advance Care Planning During COVID-19 (2020). Resource Type: Archived Webinar. Description: This town hall conversation explores the legal, policy, operational, and capacity issues related to advance care planning. More Details...

Operating a MLP During COVID-19, A Town Hall (2020). Resource Type: Archived Webinar. Description: This town hall conversation explored strategies for coordinating health and legal efforts during the COVID-19 pandemic. More Details...

Partnership Opportunities for Health Centers, EnVision Centers, and Public Housing Agencies (2020). Resource Type: Archived Webinar. Description: The recent COVID-19 crisis his highlighted the magnitude of health inequities faced by public housing residents and the need for a coordinated approach in providing health prevention and treatment, as well as the basic goods and services needed to survive, e.g., food, medicine and shelter. More Details...

The Road to Health Guided Implementation Project (2020). Resource Type: Publication. Description: The Road to Health (RTH) Guided Implementation Project is an organizational effort aimed at highlighting the efficacy of CHW programs in addressing diabetes within Health Centers (HCs). More Details...

Su Corazon, Su Vida, Your Heart, Your Life Guided Implementation (2020). Resource Type: Publication. Description: Su Corazon, Su Vida/ Your Heart, Your Life (SCSV/YHYL) Guided Implementation Project is an organizational effort aimed at highlighting the efficacy of CHW programs in addressing hypertension within Health Centers (HCs). More Details...

Medical-Legal Partnership Guide for Agricultural Worker-Serving Organizations (2020). Resource Type: Publication. Description: FJ’s Medical-Legal Partnership Guide for Agricultural Worker Serving Organizations shares strategies and resources to develop or strengthen medical-legal partnerships (MLPs) in agricultural worker communities. It highlights successful agricultural worker MLPs and resources for health centers and other agricultural worker-serving organizations. More Details...

Structural Competency: A Framework to Analyze and Address Social Determinants of Health and Health Disparities: Recorded Workshop Training (2020). Resource Type: Other. Description: This workshop introduces the Structural Competency framework and key concepts like structural violence and racism, and structural interventions. This workshop aims to provide you with the ability to discern how structures impact the health of patients and communities, and to allow participants to apply case studies relevant to health center programs. More Details...

PCA Enabling Services Virtual Summit Podcast Series (2020). Resource Type: Other. Description: The first-ever PCA Enabling Services Virtual Summit and podcast series is co-organized and hosted by the Health Center Association of Nebraska (HCAN) in partnership with Health Outreach Partners (HOP). The seven podcast episodes cover a variety of Enabling Services topics, with a focus towards Primary Care Associations. More Details...

Informational Guide for Public Housing Residents During COVID-19 – Know the Basics of Seeking Care: Know the Basics of Seeking Care (2020). Resource Type: Publication. Description: This infographic provides general information on how public housing residents can seek care for COVID-19, testing services provided by health centers near public housing agencies and how the Public Charge rule does not apply for these services. More Details...

Informational Guide for Public Housing Residents — COVID-19: Know the Basics (2020). Resource Type: Publication. Description: This infographic provides general information on COVID-19. More Details...

Social Determinants of Health for LGBTQIA+ People Part 2 (2020). Resource Type: Archived Webinar. Description: In this second installment focused on social determinants of health for LGBTQIA+ people, Adrianna Boulin, the Community Outreach & Engagement Manager for Fenway Health discusses how community-based resources can help to mitigate the effects of stigma and marginalization for sexual and gender minority people. This webinar compliments Part 1 by providing actionable solutions to many of the inequities faced by LGBTQIA+ people. More Details...

Social Determinants of Health for LGBTQIA+ People Part 1 (2020). Resource Type: Archived Webinar. Description: In this webinar Sean Cahill, PhD, the Director of Health Policy and Research at The Fenway Institute discusses social determinants of health for sexual and gender minorities. This session addresses current stressors and solutions to health inequities for LGBTQIA+ people, including the implications of COVID-19 for the community. More Details...

Sexual Health and Wellness for Older Adults Part 2 (2020). Resource Type: Archived Webinar. Description: In this second of our two-part webinar on sexual health and LGBTQIA+ Older Adults, Lisa Krinsky, LICSW and Kevin Ard, MD discuss social and care measures to support positive sexual health in sexual and gender minority elders. The session addresses social stigma toward the sexual health of older adults and provides guidance on how to best support elders in a healthy sex life. PrEP and other STI prevention and treatment measures are discussed in the context of LGBTQIA+ older adults. More Details...

Sexual Health and Wellness for Older Adults Part 1: Webinar (2020). Resource Type: Archived Webinar. Description: In this two part series, The National LGBTQIA+ Health Education Center and the National Center for Equitable Care for Elders provide guidance on how to care for the sexual health and well-being of LGBTQIA+ older adults. More Details...

Logrando Equidad en la Salud para las personas Lesbianas, Gays, Bisexuales, Transgénero y Queer (LGBTQ) – Parte 2 (2020). Resource Type: Archived Webinar. Description: Este seminario virtual en español cubrirá temas relacionados con el logro de la equidad en salud para las personas LGBTQIA+, particularmente aquellos en la intersección de las identidades latina, de minoría sexual, y de género. Esta sesión se dividirá en dos partes. La primera parte cubrirá la terminología básica, y una exploración de un modelo para entender como el estrés único de las minorías puede informar a las disparidades de salud experimentadas por las personas LGBTQIA+. More Details...

Logrando Equidad en la Salud para las personas Lesbianas, Gays, Bisexuales, Transgénero y Queer (LGBTQ) – Parte 1 (2020). Resource Type: Archived Webinar. Description: Este seminario virtual en español cubrirá temas relacionados con el logro de la equidad en salud para las personas LGBTQIA+, particularmente aquellos en la intersección de las identidades latina, de minoría sexual, y de género. Esta sesión se dividirá en dos partes. La primera parte cubrirá la terminología básica, y una exploración de un modelo para entender como el estrés único de las minorías puede informar a las disparidades de salud experimentadas por las personas LGBTQIA+. More Details...

Caring for Intersex Patients (2020). Resource Type: Archived Webinar. Description: In this webinar we will define what it means to be intersex, address common misconceptions about intersex experience, discuss specific challenges faced by the intersex communities in accessing high-quality care, and outline best practices for how providers at health centers can effectively serve intersex patients. More Details...

Tip Sheet: 3 Ways to Help Patients with Evictions and Foreclosures during the COVID-19 Pandemic (2020). Resource Type: Other. Description: This is a tip sheet that outlines 3 ways health care providers and staff can work with legal aid attorneys to help patients facing possible evictions and foreclosures while also working to strengthen long-term housing protections. More Details...

Enabling Services Data Collection: Documenting Health Center Interventions In A Value-Based Payment Environment (2020). Resource Type: Archived Webinar. Description: In collaboration with Health Outreach Partners (HOP), AAPCHO promoted the importance of documenting social determinants of health (SDoH) interventions to demonstrate the value and scope of health center enabling services (ES). AAPCHO and HOP was joined by the Community Health Care Association of New York State (CHCANYS) to highlight how state, regional, and national partners can leverage SDoH and ES data for Value-Based Payment (VBP). More Details...

Care Coordination: Planning for COVID-19 Hospitalizations: Strategies for partners pre- and post - COVID 19 Hospitalizations (2020). Resource Type: Publication. Description: This document summarizes care team roles and key recommendations specific to supportive housing residents whose CIVID-19 symptoms are severe enough to require hospitalization. More Details...

Navigating Emergency Food Resources in Times of Crisis & Beyond: Three Step Approach to Understanding food resources in your community (2020). Resource Type: Publication. Description: This brief is intended to help supportive and affordable housing and health and human service partners understand and more effectively assess resident and client access to emergency food. This navigation is especially important during unforeseen disruptions to local economies such as natural disasters, public health emergencies, or civic unrest. More Details...

Lessons Learned in Diabetes Care for Homeless Populations: Best practices from peer collaborative of health centers and supportive housing providers (2020). Resource Type: Publication. Description: This publication summarizes key barriers and promising practices in the field identified by collaborative participants related to diabetes care for individuals experiencing homelessness or formerly homeless in supportive housing. More Details...

Enhancing Social Connectedness in times of Physical Distance: Highlight promising practices for keeping connected with clients (2020). Resource Type: Publication. Description: The current need for physical distancing to prevent the spread of COVID-19 means that many people may become more isolated. Here are suggestions for how to encourage social connectedness while practicing physical distancing and following critically important CDC guidance regarding how to not spread the virus. More Details...

Care Coordination: Planning for COVID-19 Hospitalizations: Strategies for partners pre- and post - COVID 19 Hospitalizations (2020). Resource Type: Publication. Description: This document summarizes care team roles and key recommendations for COVID-19 protocols specific to supportive housing residents whose symptoms are severe enough to require hospitalization. More Details...

Addressing the Opioid Crisis: Innovative State Responses: Companion paper to Opioid Crisis webinar series highlights strategies states and local providers have developed to service the hardest hit populations (2020). Resource Type: Publication. Description: The recent increase in federal funding to address the opioid crisis presents health centers the opportunity to expand partnerships with supportive housing and substance use disorder providers. This brief for health center partners summarizes promising practices in three states; explores a managed care organization’s work with its members to address the opioid epidemic; and ways for health centers to incorporate these practices into their OUD services. More Details...

Migrant Health Centers & COVID-19 Infographic (2020). Resource Type: Publication. Description: NCFH's infographic describing the results of the most recently available survey data for Migrant Health Centers conducted by HRSA, updated weekly. More Details...

The COVID-19 Pandemic: Information and Resources (2020). Resource Type: Toolkit. Description: We at Migrant Clinicians Network have a dual priority to support clinicians and the vulnerable patients that they serve. MCN is presently developing strategies and gathering resources to support clinicians as they reach out to communities that are often overlooked and give care to patients who might otherwise have nowhere to go. We remain highly concerned for the vulnerable populations that already encounter numerous barriers to health and to care. More Details...

Community Information Exchange: Using Data to Coordinate Care for People Experiencing Homelessness: Addressing COVID-19 and Beyond (2020). Resource Type: Publication. Description: As health centers continue to build innovative models to serve people experiencing homelessness, partnerships to address the social determinants of health become more crucial. A major challenge organizations face in building and sustaining these partnerships is communication and sharing relevant information to ensure coordinated care. Community Information Exchanges (CIE) build on the work the health care system has done to set up Health Information Exchanges and takes the next step towards integrating data with other service organizations. This publication highlights what CIEs are, how they can be used, and how this could be beneficial during health care crises like COVID-19. More Details...

Developing Cross-Sector Partnerships (2020). Resource Type: Publication. Description: This guide provides health center staff with tools and strategies to initiate, develop, and sustain community partnerships to better serve older adult residents of public housing. Content of this publication was developed through a 4-session learning collaborative launched by the SDOH academy with a small cohort of HRSA-funded health centers, HCCNs, and PCAs. More Details...

Reducing Harm for People Using Drugs & Alcohol During the COVID-19 Pandemic: A Guide for Alternative Care Sites (2020). Resource Type: Publication. Description: People experiencing homelessness cannot recover or protect themselves from COVID-19 at home. Therefore, Alternative Care Sites are being developed to accommodate such clients. This issue brief is intended to provide managers of alternative care sites, including health centers, with a framework for serving individuals with SUD in isolation and quarantine, and reducing possible harmful consequences. More Details...

Why Homeless Populations Are a High-Risk Group — COVID-19 (2020). Resource Type: Publication. Description: This shareable infographic explains why people experiencing homelessness are especially vulnerable to to the coronavirus pandemic. More Details...

Toolkit on Response to Racism and Xenophobia — COVID-19 (2020). Resource Type: Toolkit. Description: The National Council of Asian Pacific Americans (NCAPA), in collaboration with the Association of Asian Pacific Community Health Organizations, developed a COVID-19 Response Toolkit to address incidents of xenophobia, racism, and hate in the Asian American (AA) and Native Hawaiian and Pacific Islander (NHPI) community. More Details...

Things to Do During the COVID-19 Crisis if You Have Diabetes (2020). Resource Type: Publication. Description: This fact sheet synthesizes the distinct advice people with diabetes who experience homelessness need to know about the COVID-19 pandemic. More Details...

Digest of Resources for Medical-Legal Partnerships — COVID-19 (2020). Resource Type: Other. Description: A digest of resources to tackle the urgent, overlapping health and legal needs exacerbated by the COVID-19 pandemic. Includes a townhall webinar highlighting remote legal practices, COVID-19-related legal needs such as eviction prevention, and practical advice from New York and Austin MLP programs. More Details...

Coordinated Entry Systems, Assessment of Vulnerability, and Housing Prioritization for People Experiencing Homelessness (2020). Resource Type: Publication. Description: It can be frustrating and confusing for people without homes to navigate complex patchworks of local homeless service organizations. This CME-accredited issue of Healing Hands focuses on how communities are implementing Coordinated Entry Systems (CESs) to help clients access necessary services through a single entry point and more efficiently coordinate assistance for people without homes. More Details...

Coronavirus Disease 2019 (COVID-19) (CDC) (2020). Resource Type: Publication. Description: This short document discusses how health center boards are exercising their governance duties related to COVID-19. More Details...

Back to School: How Health Centers Can Address Diabetes Risk: (2020). Resource Type: Archived Webinar. Description: This webinar describes evidence-based strategies for reducing diabetes risk among elementary school-aged children while highlighting the role that nurses can play in creating and sustaining those strategies. More Details...

Intersection on Homelessness and Human Trafficking: A Case Study on End Slavery Tennessee (2020). Resource Type: Publication. Description: The purpose of this case study is to provide an example of quality services for individuals with the experience of both homelessness and human trafficking. It is also intended to share signs providers can use to identify a history of trafficking and additional health considerations. More Details...

HUD Policy Brief for Health Centers - Rapid Rehousing: Health centers are increasingly participating in rapid re-housing, which helps individuals and families find stable housing with subsidies and services (2019). Resource Type: Publication. Description: Health centers need to understand the resources and how to access to support affordable housing for their clients. Rapid Rehousing is an effective housing intervention to quickly stabilize individuals and families to address their health and service needs. More Details...

Food Insecurity Among Older Adults (2019). Resource Type: Publication. Description: This publication explores the impact of food insecurity on older adults in the U.S. The publication serves as an aid for clinicians to identify strategies that can assist older Americans in averting food insecurity and its negative health outcomes. More Details...

The Road to Trauma-Informed Care in Primary Care (2020). Resource Type: Archived Webinar. Description: During this webinar, we heard from the National Council and Zufall Health Center about this program, lessons learned and resources for Health Centers on how to implement a trauma-informed care program on Trauma-Informed Primary Care: Fostering Resilience and Recovery, to educate health care providers on the importance of trauma-informed approaches and to create a change package for implementation of standardized and scalable trauma-informed care practices in the primary care setting. More Details...

Health Centers as Assets in Their Community: Assessing Your Environment (Market Assessment) (2019). Resource Type: Archived Webinar. Description: This session is designed to provide attendees with a tour of the range of research resources available for health centers to assess market opportunities (many of them are free for all to use). We will review techniques for how to determine the size and location of the low-income, uninsured and under-served population, estimate the level of unmet need, and translate this information into workforce needs and a preliminary capital project budget. More Details...

Achieving Social Determinants of Health Goals through Capital Expansion (2019). Resource Type: Archived Webinar. Description: The Social Determinants of Health (SDOH) can be a powerful framework to help health centers become an integral part of a community that sets the foundation for health. Health centers are increasingly addressing SDOH through their capital projects, such as co-located health and housing units, community gardens, gyms, and building space for financial counseling. More Details...

Enabling Services Case Study: A Focus on Food Insecurity: Native Health, Phoenix, AZ (2019). Resource Type: Publication. Description: This publication is part of a series of case studies that highlight innovative models for providing enabling services to help reduce barriers to care and address social determinants of health. This case study features Native Health, an Urban Indian Health Center that provides a suite of enabling services specifically designed to address food insecurity and promote healthy food choices. More Details...

Enabling Services Case Study: A Focus on Field-Based Services: North Carolina Farmworker Health Program (2020). Resource Type: Publication. Description: This publication is part of a series of case studies that highlight innovative models for providing enabling services to help reduce barriers to care and address social determinants of health. This case study features the North Carolina Farmworker Health Program (NCFHP) efforts to deploy an Outreach Team to provide a myriad of core enabling services to farmworkers in the field, at home, and in migrant camps. The case study highlights innovative models of providing outreach and care in addition to discussing key funding, policy, and market drivers. More Details...

Enabling Services Case Study: A Focus on Behavioral Health: Wellspace Health, Sacramento, CA (2019). Resource Type: Publication. Description: This publication is part of a series of case studies that highlight innovative models for providing enabling services to help reduce barriers to care and address social determinants of health. This case study features Wellspace Health's (WSH) "Health, Access, Referrals, and Transitions" (HART) program. WSH's HART program utilizes case management services to connect patients to care and to make care transitions to critical clinical and behavioral health services. The HART program provides intensive case management and addresses substance use disorders, suicide prevention, provides street outreach, and respite and recuperative services. More Details...

Enabling Services Case Study: A Focus on Apprenticeships: Alaska Primary Care Association Apprenticeship (2019). Resource Type: Publication. Description: This publication is part of a series of case studies that highlight innovative models for providing enabling services to help reduce barriers to care and address social determinants of health. This case study features the Alaska Primary Care Association's efforts to launch an Apprenticeship Program for Community Health Workers -- in addition to other health care related occupations -- in partnership with the state department of labor. The case study discusses both the benefits of building a support staff pipeline in addition to key components of the curriculum and funding. More Details...

Outreach and Enrollment Case Study #3: Borinquen Medical Centers of Miami-Dade (2017). Resource Type: Publication. Description: Since 2013, over 1,300 health centers nationwide have received federal funding to conduct outreach and enrollment (O&E) activities. This case study - the third produced by the National Association of Community Health Centers - examines how Borinquen Medical Centers, a federally qualified health center in Miami, FL, transformed their practice operations in order to conduct outreach and enroll uninsured community members into health insurance coverage. This case study examines the impacts that these activities had on the health center's finances, operations, and social determinants of health. More Details...

Recognizing and Responding to Domestic Violence and Human Trafficking in Health Center Settings (2019). Resource Type: n.a.. Description: This webinar provides an overview of the public health issues and the programs provided by two health centers in the United States. More Details...

Diabetes Self-Management: Education and Support (2019). Resource Type: Archived Webinar. Description: Diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes. DSMES is the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training. More Details...

Recommendations for the Care of Patients Experiencing Homelessness at Risk for or Diagnosed with Type 2 Diabetes: Adapted Clinical Guidelines (2019). Resource Type: Publication. Description: Clinicians providing health care to people experiencing homelessness routinely adapt their practice to foster better outcomes for their patients. This document has been developed to serve as a reference for members of multi-disciplinary care teams including administrators, and students serving people experiencing homelessness and are at risk for, diagnosed with prediabetes or type 2 diabetes. More Details...

Aging in Place: A Resource for Health Centers (2019). Resource Type: Publication. Description: The proportion of the world’s population over 60 years of age is projected to increase nearly double from 12% to 22% between 2015 and 2050 according to the World Health Organization (WHO). With the dramatic increase of this population, the need for programs and initiatives that address their healthy aging also increases. Ensuring that older adults have access to health care and the ability to “age in place” is a national priority both from a quality of life perspective and a cost savings perspective. More Details...

Working with the HRSA Diabetes Quality Improvement Initiative (2019). Resource Type: Archived Webinar. Description: The HRSA Diabetes Quality Improvement Initiative is an agency-wide effort to improve diabetes outcomes and lower health care costs. MCN is working in support of the Improvement Initiative by assisting you to access resources and develop performance improvement skills that will enable you to address diabetes care in your mobile and agricultural worker populations. Diabetes care is a complex mix that includes medication, as well as education, self-care behaviors and continuity of care. Adding the factors of mobility, immigration status and culture takes the challenge to another level. More Details...

What's New In PrEP and STIs?: Cases from a Sexual Health Clinic (2019). Resource Type: Archived Webinar. Description: Dr. Kevin Ard will use clinical cases to explore recent advances in HIV pre-exposure prophylaxis (PrEP) and sexually-transmitted infection prevention and treatment for LGBTQ people, discussing implications for primary and specialty care. More Details...

VA Medical-Legal Partnership Readiness Guide (2019). Resource Type: Publication. Description: Veterans are a special population with demonstrated social and legal needs that affect their health and well-being. The VA Medical-Legal Partnership Readiness Guide, developed by the National Center for Medical-Legal Partnership, provides VA medical centers with a step-by-step approach to starting and sustaining an MLP. More Details...

Transgender Health and Medical-Legal Partnerships (2018). Resource Type: Publication. Description: This fact sheet describes common social and legal needs that affect the health of transgender individuals, and ways integrated legal services can help meet those needs. It examines medical-legal partnership programs at three health care organizations and how they operate, and it shares stories of people benefiting from medical-legal partnership services. More Details...

The Role of Structural Competency in the Treatment and Prevention of Diabetes in a Vulnerable Agricultural Worker Population (2018). Resource Type: Archived Webinar. Description: Over the last 30 years, considerable attention has been paid in the clinical setting to cultural competency- the ability to mitigate against the effects of the sociocultural differences between clinicians and patients and to take into account how culture affects the symptoms presented or the patients’ attitude about health care. More recently, scholars and clinicians have encouraged those in practice or health professions training to focus not only on the behaviors and beliefs of cultural groups but more importantly to consider the structural determinants, prejudices, injustices and blind spots, the “pathologies of social systems” that affect health outcomes and the stigma experienced by patients. The session will introduce participants to the broad framework of structural competency and the five core structural competencies. Particular attention will be paid to the impact of structural issues on the treatment and management of diabetes for vulnerable populations. More Details...

The Role of Medical-Legal Partnership in Promoting Health Equity (2018). Resource Type: Publication. Description: This article shares how more than nearly 400 hospitals, health centers, and clinics across the U.S. are using legal services to treat issues–including housing, access to insurance, and stable guardianship–that drive health inequities. This commentary was published as part of a special edition of Health Affairs on “Advancing Health Equity.” More Details...

The Impact of the Workplace on Primary Care Management of the Diabetic Patient (2018). Resource Type: Archived Webinar. Description: Management of diabetes can be affected by many factors including the type of job of the diabetic patient. More importantly, poor diabetes management can compromise a workers’ ability to perform their job duties. The standard of care to regulate blood glucose such as standardized medication, activity, and food regimens may not be possible for many workers, particularly those in low-wage jobs. There may be no place to store medication or food, breaks may be limited or not regularly be offered and following a food regimen while working may not be feasible. This webinar reviews how work can impact diabetes management and offers strategies and tools to assist diabetic patients in managing their disease at work. Results from a recent study with primary care providers will be shared to highlight new recommendations for clinical decision support. More Details...

Suicide Risk Assessment and Management for LGBTQ People (2018). Resource Type: Publication. Description: This publication offers a brief summary of what is known about suicidal behavior and risk among LGBTQ people, followed by information and resources for health centers to help both young and old LGBTQ people get support and tap into internal and community resilience. More Details...

Socially Vulnerable Older Adults and Medical-Legal Partnership (2019). Resource Type: Publication. Description: The report details three medical-legal partnership programs serving older adults and their impact on preventing homelessness, improving financial stability, and other social determinants. More Details...

Social Determinants of Health Self-Assessment (2018). Resource Type: Toolkit. Description: This Social Determinates of Health Self-Assessment will help administrators determine which SDOH markers their health center patient screening process is incorporating and the success of current SDOH strategies utilized to help the agricultural worker population. More Details...

Sliding Fee Discount Program (2017). Resource Type: Publication. Description: NCFH and Farmworker Justice have created this customizable, low-literacy tool for all Migrant & Community Health Centers to help explain your patients' financial responsibility - how and what patients should expect to pay during their visit - focusing on the sliding fee scale discount program. More Details...

School-Based Health Centers & Medical-Legal Partnerships: A Partnership for Social Equity in Child and Adolescent Health (2019). Resource Type: Archived Webinar. Description: View this webinar to learn how your SBHC, through a medical-legal partnership (MLP), can provide patients with legal services for issues that directly affect their health, better organize your services and programs to address SDOH, and further increase the efficacy of health interventions. More Details...

School-Based Health and Medical-Legal Partnerships (2018). Resource Type: Publication. Description: This fact sheet describes common social and legal needs that affect the health of youth, and ways integrated legal services can help meet those needs. It examines medical-legal partnership programs at two school-based health centers and how they operate, and it shares stories of students benefiting from medical-legal partnership services. More Details...

School-Based Health and Medical-Legal Partnerships (2018). Resource Type: Publication. Description: In partnership with the National Center for Medical-Legal Partnership, this online factsheet describes common social and legal needs that affect the health of youth and ways that integrated legal services can help meet those needs. It also examines medical-legal partnership programs at two school-based health centers and shares stories of students benefiting from medical-legal partnership services. More Details...

Population Specific Approaches to SDOH: Elderly, LGBT, Migrant Workers and Public Housing Residents (2020). Resource Type: Archived Webinar. Description: Individuals within certain special and vulnerable populations experience health inequalities and therefore are at a higher risk of late detection, inadequate management and treatment of diabetes. Improved access to certain non-clinical enabling services and a comprehensive social history is essential to understanding the needs of these often overlooked individuals, and developing interventions that address those needs. More Details...

Keeping Children Safe From Lead Poisoning (2018). Resource Type: Publication. Description: This story series follows the medical-legal partnership at Erie Family Health Centers, which built a multi-state coalition to secure children’s health by updating federal regulations related to lead levels in federal housing. More Details...

Insurance Considerations and Navigating Gender Affirming Care (2019). Resource Type: Archived Webinar. Description: Cei Lambert, Program Manager for The National LGBTQIA+ Health Education Center, discusses insurance barriers and navigation solutions for assisting gender diverse patients in accessing gender affirming care. More Details...

HUD Policy Brief for Health Centers - Rural Homelessness: Understanding the Role and Impact of Housing Policy for Health Centers (Rural Homelessness) (2019). Resource Type: Publication. Description: HUD's 'All Routes Home' initiative targets resources and technical assistance to strengthen collaborations in rural communities to address needs of homeless and vulnerable populations. More Details...

How Medical-Legal Partnership Services Can Help Address the Opioid Crisis (2018). Resource Type: Publication. Description: This issue brief from the National Center for Medical-Legal Partnership examines how legal services delivered alongside medical and behavioral health services can help support successful recovery from substance use disorders. More Details...

Health Equity Starter Kit (2019). Resource Type: Starter Kit. Description: To best support health centers who are committed to serving vulnerable and underserved populations, HOP created the Health Equity Starter Kit. The Starter Kit contains resources related to health equity all in one place. This resource provides support in better understanding health equity as a broader framework to explain and address structural factors, social determinants of health, and health disparities. The Starter Kit includes a collection of innovative strategies, as well as examples of data and measures to track and evaluate health equity efforts. More Details...

Ensuring People with Chronic Conditions Maintain Access to Care (2018). Resource Type: Publication. Description: This story series follows the Whitman Walker Health Center medical-legal partnership team as they helped prevent platinum insurance plans that were widely used by patients with chronic conditions from being eliminated in the D.C. Marketplace More Details...

Eliminating Hurdles to Life Saving Medication (2018). Resource Type: Publication. Description: This story series follows the Whitman-Walker Health medical-legal partnership, which worked with insurance companies to remove requirements forcing Post-Exposure Prophylaxis medications to be filled by mail More Details...

Diabetes Prevention and Management for LGBTQ People (2019). Resource Type: Publication. Description: In this publication, we discuss diabetes risk factors unique to LGBTQ people, and make recommendations for screening and management of diabetes in LGBTQ populations. More Details...

Diabetes Management and Oral Health Among Older Adults Experiencing Homelessness: Promising and Evidence-Based Practices for Health Centers in Diabetes Management and Oral Care (2020). Resource Type: Archived Webinar. Description: This webinar addressed the burden of diabetes among older adults who have experienced homelessness and the burden of periodontal disease among this population; the role of supportive housing as a key social determinant in improving health outcomes, including connections to quality dental care; and promising and evidence-based practices aimed at improving overall dentition among older adults with diabetes who are homeless or formerly homeless. More Details...

Diabetes Management and Oral Health among Older Adults Experiencing Homelessness (2019). Resource Type: Publication. Description: This publication highlights the diabetes disease burden and gum (periodontal) disease among older adults (50+) who have experienced or are experiencing homelessness and explores promising and evidence-based practices health centers can adopt, aimed at improving overall oral health among this population. More Details...

Cost of Care Resources (2019). Resource Type: Toolkit. Description: n.a. More Details...

Considerations for Heart Health for LGBTQ Identified Patients (2019). Resource Type: Archived Webinar. Description: Lisa Neff, Community Impact Director at the American Heart Association and Dr. Alex Gonzalez, Medical Director at Fenway Community Health, will discuss cholesterol, diabetes, and other heart health considerations as they pertain to the LGBTQ community. The webinar will cover strategies for care including the AHA's Check. Change. Control, Cholesterol program and diabetes management strategies tailored to the needs of LGBTQ people. More Details...

Complex Care Health Settings and Medical-Legal Partnerships (2019). Resource Type: Publication. Description: This fact sheet describes five complex care settings that have integrated medical-legal partnership services into care delivery to tackle SDOH. It also features data on the ways these partnerships have demonstrated initial success in improving both physical and mental health conditions as well as stabilizing income and housing for patients with complex conditions while also curbing costly overuse of health care services by addressing the root causes of patients’ problems. More Details...

Competency Checklist for Bilingual Staff (2018). Resource Type: Toolkit. Description: The Competency Checklist for Bilingual Staff will help health centers to assess the interpretation competencies of bilingual staff that have no formal interpretation training or certification, but areasked to interpret during clinic encounters. More Details...

CLAS Self-Assessment Tool (2018). Resource Type: Toolkit. Description: This assessment tool can assist CHCs to determine the status of CLAS implementation strategies within their organization. More Details...

Behavioral Health Integration Compendium: Curated Guidance and Resources from Experienced Organizations, developed with Chiron Strategy Group (2018). Resource Type: Publication. Description: Many health centers collaborate with external behavioral health providers or provide co-located or integrated behavioral health services within their health center. Some of the most significant challenges are determining which data to share, how to store it within the Electronic Health Record, and how to use it within primary care. This compendium of literature and resources offers some guidance related to behavioral health data integration, complete with key health center considerations for each. Many health centers collaborate with external behavioral health providers or provide co-located or integrated behavioral health services within their health center. Some of the most significant challenges are determining which data to share, how to store it within the Electronic Health Record, and how to use it within primary care. This compendium of literature and resources offers some guidance related to behavioral health data integration, complete with key health center considerations for each. Click on each heading below to access the original pieces being profiled. Integrating Behavioral and Primary Care — Technology and Collaboration This article focuses on the challenges of integrating data between primary care and behavioral health. It discusses a number of concerns, and approaches that have been taken, including the benefits of developing structured data within the EHR. Health Center Takeaway: Patient consent for sharing sensitive health information can be integrated into the EHR, which will allow for greater information sharing while complying with Federal privacy expectations. Can technology shape the future of behavioral health? This article includes a number of different ways that technology plays a part in integrated behavioral health, highlighting: Adoption of telehealth as a means to augment care; Inclusion of behavioral health data in Health Information Exchanges, citing the experience of Arizona; and An example of an application being developed with NIH support that hopes to provide collaborative care tools to patients. Health Center Takeaway: Health centers are encouraged to investigate whether insurers will reimburse for telehealth and what is required to do so, to see if developing a telehealth program might augment the availability of behavioral health services for your patients. HITEQ has a number of resources related to telehealth. Integrated Behavioral Health Partners Three Case Studies on Behavioral Health Data Sharing Three California case studies where organizations shared behavioral health data.  The website includes details regarding mental health data, substance use data, consent, methods of sharing, and challenges. Health Center Takeaway: Use these examples of different approaches to consent and level of information sharing to foster conversation among your leadership on how to create greater data integration. Center for Health Care Strategies Integrating Physical and Behavioral Health Care in Medicaid Toolkit Section IV: Information Exchange CHCS has developed a rich resource for behavioral health integration.  This section focuses on information exchange, and has a number of helpful resources identified. Health Center Takeaway: The last two resources are integrated care plan templates; if you have an external behavioral health partner, consider how you might share data between the two organizations in a standardized format. Patient-Centered Primary Care Institute Behavioral Health Integration: Obstacles & Successes Lessons learned from this interview: Change the mindset from the bringing together of two services to truly integrating whole health Shift from historic care delivery methods to a focus on achieving better health outcomes Building trust with primary care providers is essential Health Center Takeaway: Determining what patients need will help guide the type of integration services your health center develops, which can include different approaches for different sites. SAMHSA’s Quick Start Guide to Behavioral Health Integration for Safety-Net Primary Care Providers This guide helps any health center think about where it is in the process of integrating behavioral health, with a number of embedded links for additional information. Key areas of Administration, Workforce, and Clinical Practice. Health Center Takeaway: Use this guide to identify barriers to a fully-developed program, and find resources to help overcome them. Zufall Health Center Integrated Behavioral Health and Primary Care Change Package Zufall Health Center partnered with a local behavioral health system to create an Integrated Behavioral Health system, using grant funding to help support the pilot. This collection of lessons learned focuses on: Leadership Commitment Clinical Information Systems and Measurable Improvement Integrated Care Delivery Clinical Decision Support Patient/Family Engagement Health Center Takeaway: Leadership must assess organizational capacity to collaborate, and then collect baseline data on health outcomes, including preventative screenings, ED visits, hospitalizations as some of the early steps. Implementing measurement and management of key clinical outcomes are critical next steps. NCQA Mainstreaming Behavioral Health Care NCQA has developed a Distinction in Behavioral Health Integration, which allows recognition of Patient Centered Medical Homes who have integrated care teams in place using evidence-based protocols and ongoing quality measurement and improvement. Health Center Takeaway: Many health centers have achieved recognition as a Patient Centered Medical Home PCMH or are along the way.  Aligning behavioral health integration work to earn this Distinction can help provide a roadmap for implementation of integration activities, and externally create validation for potential funders. How Intermountain Healthcare's Mental Health Integration is Improving Care Intermountain Healthcare is a large health system, with 22 hospitals and 180 clinics. It has been developing Mental Health Integration services for a number of years, with three key components: Their mental health assessment tool activates a team consultation workflow to determine which patients are referred. They designed an operational system in which mental health specialists and nurse care managers are included in the primary care staff, through full-time co-location or frequent rotation.They evaluate the program regularly to monitor patient outcomes, team effectiveness and the culture of healthcare delivery from the perspective of the patient and the care provider. Health Center Takeaway: Integrating behavioral health takes time. Intermountain Healthcare has created an efficient process to develop programs and they plan for two years to implement and become revenue-neutral. Health centers would benefit from a long-term approach with a commitment of upfront internal or external funding.   Deeper Reading If you are looking for more in-depth reading on the topic, visit the following links for longer articles. Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care This Journal of the American Board of Family Medicine article describes the electronic health record EHR-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology HIT solutions that emerged during implementation. Behavioral Health Information Network of Arizona: 2014 HIMSS HIE Community Roundtable This HIMSS presentation describes the design and implementation of a Health Information Exchange in Arizona that integrates behavioral health data and is 42 CFR Part 2 compliant.  Useful for any health center leadership involved in such a project with their affiliated Health Information Exchange. More Details...

Ag Worker Needs Assessment (2018). Resource Type: Toolkit. Description: Agricultural Worker Community Needs Assessment helps health centers assess the health care needs of the local agricultural worker population. The toolkit, located in the Needs Assessement tab on the Health Center Toolbox webpage, includes an Introduction, Points to Remember, Sample Policy & Procedure, Determining What Information is Needed, and sample needs assessments in English and Spanish. More Details...

Addressing the Transportation Needs of Older Adults (2018). Resource Type: Archived Webinar. Description: Safe and accessible transportation is a top concern for older adults, caregivers, and their communities. As adults age, maintaining mobility is fundamental to their health and quality of life. More Details...

Addressing Structural Vulnerabilitiesin Healthcare for Migrant and Seasonal Agricultural Workers (2018). Resource Type: Archived Webinar. Description: In this webinar we will examine the structural vulnerabilities of migrant and seasonal agricultural workers through the lens of immunization disparities, opioid misuse and pain management. The faculty will present a series of case studies to illustrate the real-world impact of structural vulnerabilities on this population. Faculty will also introduce practical tools and information about structural vulnerabilities which can be incorporated into medical education to meet key domains as outlined in the AAMC Competency-Based Learning and Assessment project. More Details...

Addressing Social Determinants of Health for LGBT People (Part 2) (2018). Resource Type: Archived Webinar. Description: In the second part of the series, Dr. Cahill will address ways to provide health care to LGBT patients while acknowledging Social Determinants of Health and describe steps that health centers can use to address trauma of LGBT people experiencing health disparities and stigma. The webinar will also address policy solutions that support LGBT people and reduce vulnerability to health disparities. More Details...

Addressing Social Determinants of Health for LGBT People (Part 1) (2018). Resource Type: Archived Webinar. Description: This webinar will address social determinants of health (SDOH) that can increase the vulnerability of LGBT people to health disparities. These include poverty, homelessness, housing, discrimination, minority stress, incarceration, health care, and education. More Details...

Addressing HIV and Sexually Transmitted Infections Among LGBTQ People: A Primer for Health Centers (2019). Resource Type: Publication. Description: Some lesbian, gay, bisexual, transgender, and queer (LGBTQ) people face an increased risk for HIV and sexually transmitted infections (STIs). The increased risk of HIV and STIs in these populations stems from both social and biological factors.Health center clinicians can help address HIV and STIs among LGBTQ people by screening appropriately based on a comprehensive sexual history, providing culturally appropriate safer sex counseling, and offering biomedical prevention strategies, such as vaccinations and pre-exposure prophylaxis for HIV (PrEP). More Details...

NNOHA Operations Manual - Quality Chapter (2019). Resource Type: Publication. Description: Health centers strive to deliver quality care that leads to positive patient outcomes. This chapter of the NNOHA Operations Manual will explore quality improvement for oral health programs. More Details...

Promoting CDC Tips from Former Smokers to Public Housing Residents (2018). Resource Type: Archived Webinar. Description: This webinar provided background on the smoking rates for public housing residents, the recent requirement for public housing buildings to implement a smoke-free policy, and an overview of CDC Tips materials and resources (such as Tips print ads and videos) tailored for health care providers and organizations that serve public housing residents. It also provided details on the pilot project and information on how to apply. More Details...

Social Determinants of Health for Public Housing Residents: Diabetes (2019). Resource Type: Publication. Description: Public housing residents are more likely to be affected by community violence and chronic medical conditions such as diabetes. The following issues brief provide descriptions of some of the most critical issues affecting this special population. More Details...

Health Behaviors and Public Housing: Interactive Map (n.a.). Resource Type: Other. Description: Health behaviors are detrimental actions that heightened the odd of illness and impede recovery. This map depicts some health behaviors by county and the location of PHPC health centers in the nation. More Details...

Cervical Cancer Screening Strategies in Public Housing Primary Care Settings: Findings from the NCHPH Learning Collaborative (2018). Resource Type: Publication. Description: A cervical cancer prevention and control program comprises an organized set of activities aimed at preventing and reducing morbidity and mortality from cervical cancer. The program provides a plan of action with details on what work is to be done, by whom and when, as well as information about what means or resources will be used to implement the program. More Details...

Cervical Cancer Prevention Strategies in Public Housing Primary Care Settings: Findings from the NCHPH Learning Collaborative (2018). Resource Type: n.a.. Description: The National Center for Health in Public Housing (NCHPH) engaged in discussions with clinical directors from Public Housing Primary Care grantees and other Health Centers located in or immediately accessible to public housing to determine successful strategies to promote cervical cancer prevention among their patient population. More Details...

Increasing Access to Healthy Food and Exercise in Public Housing Communities: Examples From Public Housing Primary Care Grantees (2019). Resource Type: Publication. Description: Public housing residents face the challenge of living in communities with poor access to healthy foods and safe places to exercise. Addressing access to healthy food and improving diet and exercise are critical components in improving the health of public housing residents. This report provides examples of Public Housing Primary Care Grantee strategies and programs that have increased access to healthy food, exercise and weight control models for public housing residents. More Details...

The Health Equity Starter Kit: A Brief Tutorial: Coffee Break Webinar (2019). Resource Type: Archived Webinar. Description: This Coffee Break Webinar is intended for anyone interested in using HOP’s free online tool, the Health Equity Starter Kit. In this session we describe how to best navigate our Health Equity Starter Kit, and highlight examples of some of the available resources within each section. More Details...

Pre-Exposure Prophylaxis (PrEP) for HIV Prevention: Considerations for Individuals Experiencing Homelessness (2019). Resource Type: Publication. Description: Despite major advancements in HIV testing, treatment, and prevention, HIV diagnoses in the United States have remained stable since 2013. The introduction of Pre-Exposure Prophylaxis (PrEP) has offered an opportunity to significantly reduce HIV transmission rates, yet those most at risk are not the ones utilizing this method of prevention. This fact sheet explores the intersection of HIV and homelessness, focusing on subpopulations with disproportionate rates of infection. It also provides promising practices in prevention and treatment, including recommendations around the initiation of PrEP in the Health Care for the Homeless setting. More Details...

Health Equity Starter Kit (2018). Resource Type: Publication. Description: The Health Equity Starter Kit contains resources related to health equity all in one place. This resource will support you in better understanding health equity as a broader framework to explain and address structural factors, social determinants of health, and health disparities. The Starter Kit includes a collection of innovative strategies, as well as examples of data and measures to track and evaluate health equity efforts. More Details...

Addressing Diabetes Factors in Elementary School Children Through School and Community Partnerships (2019). Resource Type: Publication. Description: This resource highlights ways health centers (such as federally qualified health centers) can enhance health outcomes of elementary-aged children with obesity and other pre-diabetic through school partnerships. More Details...

Community Health Centers Meeting Rural Health Needs (2019). Resource Type: Publication. Description: This short fact sheet covers the barriers to care faced by rural communities and how Community Health Centers are helping to address those barriers: by focusing services on communities with the greatest difficulty accessing or affording care, innovating using telehealth technologies, and recruiting a wide range of health care providers to complement primary care, including dentists, pharmacists, and behavioral health professionals. Ultimately, health centers are achieving better improving outcomes for rural patients. More Details...

Panel Management in the Age of Value-Based Care: Health Center Case Studies Developed with Chiron Strategy Group, June 2019 (2019). Resource Type: Publication. Description: This downloadable HITEQ resource offers guidance on improving panel management activities, including real-life examples from two health centers of the challenges and successes in managing panels. More Details...

Effective Partnerships Guide: Improving Oral Health for Migrant and Seasonal Head Start Children and their Families (2018). Resource Type: Publication. Description: The purpose of this guide is to create an opportunity for Migrant and Seasonal Head Start (MSHS) programs and health centers to learn more about each other’s programs, share resources, foster new partnerships and strengthen ones already in place. Although the guide focuses primarily on oral health, information about medical health services is included. More Details...

Improving the Health Outcomes of Both Patients AND Populations (2019). Resource Type: Archived Webinar. Description: This national webinar focuses on empowering health centers to initiate a population health strategy at their organization. More Details...

Health Centers are Providing Care to Growing Numbers of Patients with Complex Needs (2019). Resource Type: Publication. Description: This short fact sheet explains the growth in health center patients who experience higher rates of chronic conditions and social risk factors associated with poorer health outcomes, like poverty and homelessness. The fact sheet also highlights how health centers’ comprehensive services are working to address patients with complex health care needs. More Details...

Helping Kids Get At-Home Care (2018). Resource Type: Publication. Description: What would you do if your one-year old child depended on a ventilator to breathe, and the home nursing care needed to monitor it wasn’t available? Would you keep your child in the hospital indefinitely? Would you quit your job to be home with your child, and stay up all night to make sure they didn’t stop breathing? Would you put them in a long-term nursing facility 80 miles away where they’d have the care they needed, but where you wouldn’t see them for days at a time? In 2015, for several parents in Washington State, the heartbreaking answer to all these questions was yes. More Details...

Medical Respite Care Programs & the IHI Triple Aim Framework (2019). Resource Type: Publication. Description: This policy brief takes a look at the Institute for Healthcare Improvement’s (IHI) Triple Aim framework and how medical respite care programs can add value to help health centers meet the three improvement goals of this model—population health, the patient’s experience of care, and the per capita cost of health care. More Details...

Medical-Legal Partnership Origin Story: People's Community Clinic in Austin (2018). Resource Type: Publication. Description: This issue brief traces an Austin TX health center's efforts to build an MLP, including planning process, how the nuts and bolts of the partnership came together, and how it’s expanded over time. More Details...

Understanding And Combating Stigma: A Toolkit For Improving Care And Support For People Affected By HBV (2017). Resource Type: Toolkit. Description: This toolkit is written for health care providers and community health advocates who want to improve the care and support for people affected by HBV. The aim of this toolkit is to support you and anyone you are working with to confront and reduce the stigma associated with HBV, and to promote increased prevention, care and treatment of hepatitis B. Anyone can get HBV. We need to work together to promote understanding and action to combat HBV-related stigma and discrimination to combat this disease. More Details...

Stepping into the Cost of Care Conversation (2019). Resource Type: Archived Webinar. Description: The current state of cost-of-care (CoC) conversations at many clinics leads to frequent misunderstandings and unmet CoC needs, which may ultimately increase the work and costs for both patients and their healthcare providers. More Details...

Financing Medical-Legal Partnerships: View From The Field (2019). Resource Type: Publication. Description: To date, over 350 health organizations - including over 120 HRSA funded health centers -have implemented medical-legal partnerships (MLPs). This fact sheet draws on national survey data from these organizations and their partnering legal organizations to describe programs’ average budgets as well as a variety of health, legal, and philanthropic funding streams that currently fund MLPs. It also discusses how MLPs are adapting to meet their funding challenges and highlights examples of programs implementing innovative Medicaid financing models to pay for MLP services. More Details...

Complicated Conversations on Cost: MCN Research Article (2019). Resource Type: Publication. Description: This new MCN publication joins a growing body of research pieces and articles detailing the complexity around having a cost of care conversation. Last week, the New York Times published a piece entitled, “They Want It to Be Secret: How a Common Blood Test Can Cost $11 or Almost $1,000.” Using the routine metabolic blood panel as the example some insurance companies provide consumers with tools to help shed light on cost, but in many cases you won’t know the price your insurance company agreed to until you get the bill. More Details...

Addressing Intimate Partner Violence Series: Session 1: CREATING A SUPPORTIVE CLINICAL ENVIRONMENT TO ADDRESS INTIMATE PARTNER VIOLENCE (2019). Resource Type: Archived Webinar. Description: Intimate partner violence (IPV) occurs in all segments of our society, but vulnerable populations like migrant women may encounter additional disparities and barriers to care that make intervention and treatment of IPV more complex. In these two sessions, Migrant Clinicians Network provides specific and effective action items to better serve women who have experienced IPV in the exam room, and to make our communities safer by engaging men in the community. More Details...

Addressing Intimate Partner Violence Series: Session 2: PROVIDING ESSENTIAL TOOLS FOR MEN TO ACT ON PREVENTING INTIMATE PARTNER VIOLENCE (2019). Resource Type: Archived Webinar. Description: Intimate partner violence (IPV) occurs in all segments of our society, but vulnerable populations like migrant women may encounter additional disparities and barriers to care that make intervention and treatment of IPV more complex. In these two sessions, Migrant Clinicians Network provides specific and effective action items to better serve women who have experienced IPV in the exam room, and to make our communities safer by engaging men in the community. More Details...

Environmental and Occupational Screening Questions for the Primary Care Setting: Preguntas para sondear en los lugares de atencion a la salud (2007). Resource Type: Publication. Description: Three concise and effective environmental/occupational health screening questions for the primary care provider. English/Spanish resource More Details...

Environmental and Occupational Health Screening Questions for the Primary Care Setting: Preguntas para sondear en los lugares de atension a la salud (2017). Resource Type: Publication. Description: Three concise and effective environmental/occupational health screening questions for the primary care provider. Electronic Health Record Version English/Spanish resource. More Details...

HIV Prevention in the South: Reducing Stigma, Increasing Access (2016). Resource Type: Publication. Description: The HIV epidemic disproportionately affects the Southern U.S., where 51% of new HIV diagnoses occurred in 2013. Despite substantial progress along the continuum of care, HIV remains a major health concern in the South, particularly for young, Black gay and bisexual men, other men who have sex men (MSM), and transgender women. Our new publication “HIV Prevention in the South: Reducing Stigma, Increasing Access” presents four strategic elements for preventing the further spread of HIV among vulnerable populations in the South, and suggests a more hopeful future for reducing the HIV epidemic. More Details...

Getting to Zero: Reducing HIV Incidence through Screening, Treatment, and Prevention (2016). Resource Type: Online Self-Paced Learning Modules. Description: This module will: Describe HIV incidence, particularly among men who have sex with men and transgender women. Identify the current recommendations for HIV and STI screening and the importance of screening high risk populations for prevention of HIV. Describe how biomedical interventions including treatment as prevention, PEP, and PrEP are effective tools for reducing the incidence of new HIV cases among high risk populations. More Details...

Black MSM and PrEP: Challenges and Opportunities (2017). Resource Type: Archived Webinar. Description: Although estimates of HIV incidence remain relatively stable in the United States (US), the epidemic continues to increase disproportionately among men who have sex with men (MSM). Notably, nearly half of new HIV infections occur in the South, where Black/African American, young MSM (YMSM, 18 to 35) are at greatest risk. PrEP is a highly effective HIV prevention strategy. While the data about its safety and efficacy in this population are encouraging, structural and social barriers that undermine optimal PrEP uptake, as well as suboptimal adherence and retention in PrEP-related, follow-up medical care must be addressed. More Details...

WEBINAR | Structuring HIV Care for Mobile HIV Patients (2015). Resource Type: Archived Webinar. Description: Participants of this webinar will discuss barriers and interventions that can assist clinicians in meeting the needs of those living with or effected by HIV/AID. More Details...

Adapting Your Practice: Treatment and Recommendations for Unstably Housed Patients with HIV/AIDS (2013). Resource Type: Publication. Description: Clinical practice guidelines for people with HIV/AIDS who are unstably housed are fundamentally the same as those for the stably housed. However, primary care providers who routinely serve unstably housed patients recognize an increased need to consider the patient's living situation, co-occurring disorders, and motivation to remain in HIV care and adhere to treatment. This guide is meant to address these complicating factors for clinical providers. More Details...

Treatment Models for Non-Opioid Substance Use Amongst Populations Experiencing Homelessness (2019). Resource Type: Publication. Description: This edition of Healing Hands complements a previous issue of Healing Hands, “Non-Opioid Substance Use, Mental Health, and Homelessness,” which contained information about the health impacts and demographic variance of substances that are commonly used by people experiencing homelessness, as well as guidance on confronting and reducing social stigmas about substance use. This issue focuses a lens on treatment by first examining treatment models and pharmacological interventions for substance use disorder, followed by information about additional tools that may assist care providers in providing comprehensive client-centered, trauma-informed physical and mental health care and harm reduction interventions. More Details...

Non-Opioid Substance Use, Mental Health, & Homelessness (2019). Resource Type: Publication. Description: This issue of "Healing Hands" highlights the relationship between non-opioid substance use disorder, mental health, and homelessness. Approximately half of people experiencing homelessness have diagnosable substance use disorders at some point in their lives and experience stigma, serious mental illness, and poor health outcomes as a result. More Details...

Health Policy Bulletin: Green Tobacco Sickness (2019). Resource Type: Publication. Description: FJ's Health Policy Bulletin summarizes recent developments in research and policy that impact agricultural worker health. The 2019 Health Policy Bulletin highlights policy and research to mitigate the harm of Green Tobacco Sickness (GTS) among agricultural workers. More Details...

Strategies for Diabetes Awareness, Prevention and Control: Focusing on Prediabetes/Addressing Socioecological Determinants of Prediabetes and Diabetes (2017). Resource Type: Meeting Notes. Description: The world is in the midst of parallel and rapidly advancing epidemics – obesity and type 2 diabetes – that begun in the latter of the 20th century and continue to grow, unchecked. Currents prevalence rates are staggering and are expected to climb over the ensuing decades. In 2015, health centers in or immediately accessible to public housing served 590,393 diabetics, 186,268 (32 percent) of these patients have a HbA1c>9. This learning collaborative addresses strategies for diabetes awareness, prevention and control, and the socioecological determinants of prediabetes and diabetes. More Details...

Improving Diabetes Management in Primary Care: Building Community Linkages to Address the Diabetes Epidemic, Exercise and Weight Control (2017). Resource Type: Meeting Notes. Description: Past efforts describing clinical and community linkages have laid important strategies to develop prevention programs and exploring specific types of clinical and community partnerships targeted to the improvement of health services for diabetic patients. Several important initiatives have attempted to demonstrate the potential for clinical and community linkages and describe the barriers and the solutions to these barriers. The Chronic Care Model acknowledges the importance of linkages with the community for peer support, care coordination, and community-based interventions. Community-practice partnerships are important with elders, low-income, and underserved populations. This Learning Collaborative explores Health Center community addresses the diabetes epidemic. More Details...

Promoting CDC Tips® Campaign Materials to Public Housing Residents (2019). Resource Type: Publication. Description: Public housing residents are more likely to smoke and suffer from health conditions that are exacerbated by smoking and secondhand smoke exposure. The objectives of this study were to educate health care providers on the CDC Tips® From Former Smokers resources, to increase access to smoking cessation materials for public housing residents and the health care providers that serve them, and to evaluate the pilot project. More Details...

Addressing Violence in Public Housing Communities: Case Examples of Violence Prevention and Intervention Strategies from Public Housing Primary Care Grantees (2019). Resource Type: Publication. Description: The purpose of this report is to provide Health Centers located in or immediately accessible to public housing with best practices and examples of violence prevention and intervention programs that can be implemented in their communities. NCHPH conducted background research on violence and crime statistics from the Federal Bureau of Investigation Uniform Crime Reporting Program, interviewed four Health Center staff, and analyzed the interviews to identify overlapping themes, lessons learned, and successful strategies used to address and prevent violence. More Details...

Community Health Center Chartbook: January 2019 (2019). Resource Type: Publication. Description: This chartbook is a comprehensive collection of important research findings on community health centers and provides a detailed picture of the Health Center Program, including health center services, cost-effectiveness, quality of care, accessibility of services, patient demographics, and the challenges health centers face in meeting demand for care. More Details...

Lead Screening: Innovative Strategies to Increase Screening for Children (2017). Resource Type: Publication. Description: This publication summarizes community-based strategies for protecting children from lead poisoning through increased screening. More Details...

Innovative Strategies to Increase Screening of Children for Lead Poisoning (2017). Resource Type: Archived Webinar. Description: This webinar covers community-based strategies for protecting children from lead poisoning through increased screening. More Details...

Niños Saludables: Child and Family Physical Activity & Nutrition Program Implementation Guide (2018). Resource Type: Publication. Description: The Niños Saludables Facilitator’s Guide aims to increase knowledge of healthy lifestyles and promote physical activity among youth and families. More Details...

Workflows to Collect Standardized NonClinical Data (2018). Resource Type: Archived Webinar. Description: This webinar will provide an overview of different health center-tested workflow models to collect standardized data on non-clinical, social determinant of health needs using he national standardized social determinants of health risk assessment protocol known as PRAPARE. The webinar will walk through different workflow models and their associated trade offs while also providing strategies to help health centers determine which models will work best in their own clinic's workflow. More Details...

Why Collect Standardized Data on Social Determinants of Health?: A slide deck outlining the potential use of ICD10 coding for SDOH. (2017). Resource Type: Publication. Description: This resource will equip health center stakeholders with the motivation, knowledge, and ability needed to collect and use standardized social determinants of health data. This resource describes the importance of collecting Standardized SDOH Data in the context of value based payment.  The resource reviews commonly used codes in ICD-10 that can help document SDOH.  Finally, the slide deck describes useful tools for collecting these data and what’s on the horizon for health centers to strengthen their efforts to move “upstream” in addressing health disparities. Download this slide deck below. More Details...

Who Are Frequent Users in Health and Housing Systems?: A Closer Look at Definitions Used by Communities to Identify the People Cycling Through the Crisis Care Systems (2015). Resource Type: Archived Webinar. Description: Is your community looking at how to identify the frequent users across multiple crisis care systems in an effort to deliver more effective services and save resources? This webinar highlights how various communities develop the criteria to define 'frequent user' across the systems of care and how to match data to identify those individuals. More Details...

Using your EHR for Population Health Management: A Cross-reference Tool (2017). Resource Type: Publication. Description: 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. This Excel spreadsheet has three tabs. Be sure to read Tab 1, “Approach” for guidance in interpreting the information provided by this tool. Tab 2 provides a crosswalk between native certified-EHR functionality and the elements of PHM. Tab 3 contains links to EHR certification specifications on HealthIT.gov for assistance in interpreting EHR certification standards.   Background Health centers are interested in implementing population health management (PHM), but often lack the resources to purchase specialized PHM software suites to implement in conjunction with their EHR. We assessed the functionality of certified EHRs to assist health centers in utilizing native EHR capabilities to perform PHM functions.   Methods There is no standardized consensus definition of population health management (PHM). We conducted a review of the literature to identify models and elements of PHM to develop a framework for assessing the degree to which native EHR capabilities perform the functions of PHM. We synthesized results of a recent scoping review of the literature (see references) and a comparison of PHM vendor functionality to arrive at a working definition of PHM and its essential elements. Our working definition of PHM maps to the triple aim: Population Health Management is the set of activities that simultaneously improve the health status and health outcomes of a population while improving quality and reducing per capita costs. We synthesized the literature to develop a framework for the essential elements of PHM: Identify patient subpopulations by user selected parameters and perform risk stratification Examine detailed characteristics of patient subpopulations in terms of health status and outcomes, and trigger targeted care Track clinical performance measures to assess the effect and improve interventions Integrate Data - Input and aggregate data within the EHR database Share data with external systems Create and send notifications to provider and patient Aggregate and analyze data within EHR data base We then mapped the functionality included in certified EHR systems against these essential elements of PHM, to create the EHR-PHM Crosswalk presented on the next tab.   Workbook Contents Tab 1 - Approach Tab 2 - Crosswalk  This tab lists required functionality inherent to all certified EHRs. Columns show how this functionality maps to the elements of PHM. Tab 3 - Certification Detail  This tab provides links to the Certification Companion Guide on HealthIT.gov for convenient access to the specifications behind each certification requirement.   Conclusions Native EHR functionality can be used to perform the elements of PHM. Certified EHRs, regardless of vendor, may be used to implement a comprehensive PHM program that performs all of the essential elements of PHM. In addition, certified EHR functionality and the EHR data base may be used to underpin the more advanced analytics functionality, and a more robust PHM user interface provided by specialized PHM suites and EHR add-ons offered by vendors. What you can't do with a certified EHR alone: Successful, robust PHM that manages risk associated with a population of patients necessitates integrating data on utilization and cost of care provided outside of the primary care provider's EHR. This requires some form of data import and/or integration such as provided by a data warehouse, HIE, all-payer database, or other infrastructure. This infrastructure typically includes multi-source integration of data within and external to the organization; in-depth, robust analytics capabilities; and a menu-driven, user-friendly interface. These functionalities are NOT inherently provided through standard EHR certification requirements, but may be available in some vendors’ offerings as add-ons or bundled functionality.   For More Assistance Using the native functionality of EHRs to conduct PHM may require the availability of and expertise in additional tools such as registries, excel, SQL or a reporting tool such as Crystal Reports. For consulting and assistance in applying these tools to customize your EHR for PHM, request HITEQ technical assistance here.   References Steenkamer Betty M., Drewes Hanneke W., Heijink Richard, Baan Caroline A., and Struijs Jeroen N.. Population Health Management. February 2017, 20(1): 74-85. doi:10.1089/pop.2015.0149. Public Health Informatics Institute. 2016. "Population Health Management Software: An Opportunity to Advance Primary Care and Public Health Integration." Decatur, GA: Public Health Informatics Institute. Jeroen N. Struijs, Hanneke W. Drewes, Richard Heijink, Caroline A. Baan, How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework, Health Policy, Volume 119, Issue 4, April 2015, Pages 522-529, ISSN 0168-8510, http://dx.doi.org/10.1016/j.healthpol.2014.12.003.     More Details...

Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources: We asked the questions, now what? Updated in December 2018 (2018). Resource Type: Publication. Description: The collection of data related to patients' non-medical needs through use of Social Determinant of Health SDoH assessment tools, can accelerate systemic population health improvement, as well as engage patients in addressing their social non-medical needs such as transportation, shelter, or intimate partner violence services through coordinated access to appropriate services. This case study discusses the process a health center may use to identify and stratify need, and profiles a number of new technologies, including Aunt Bertha, Now Pow, and 211 Community Information Exchange, for connecting patients to appropriate community resources.   Download full case study at the bottom of the page. The collection of data related to patients' non-medical needs such as transportation, housing, food security, safety, etc. through use of Social Determinant of Health SDoH assessment tools e.g., NACHC’s PRAPARE, AAFP’s The EveryONE Project, can accelerate systemic population health improvement, as well as engage individual patients in addressing those needs through coordinated access to appropriate services.  According to a 2017 American Academy of Family Physicians AAFP survey, 83% of respondents agreed that family physicians should identify and help with social determinants of health. Research from Kaiser Permanente suggests that, of those patients screened for social determinants of health, approximately two-thirds needed some services. PRAPARE pilot data from participating health centers identified housing, utilities, and food as the most frequently identified needs. Unfortunately, 80% of the family physicians surveyed by AAFP responded that they don’t have time to discuss social determinants of health with patients and more than half feel unable to provide their patients with solutions.  So, tools are needed to help providers meet these newly identified needs, with existing resources. A number of these tools are profiled in the resource available for free download below. Much like other screenings that are embedded in the regular workflow and used to assess the risk or severity of the patient’s condition, such as the PHQ-9, Social Determinants of Health assessment tools like PRAPARE are designed to operate similarly.  Identifying level of risk or need among patients screened for social determinants of health in order to strategize responses is generally done with ‘risk scoring’. Here are two examples: SDoH only: A health center could assign 1 point per social determinant of health identified. Multiple sources: A health center could assign points based on number of chronic conditions, medications, ED visits in the last 12 months, and SDoH, as discussed in this HITEQ population health presentation. Whatever approach is taken, it is important to look at the distribution of risk scores or need levels across the patient population to ensure reasonable proportions identified as high, moderate, and low. Note that Care Management, Competency A in the PCMH 2017 standards is concerned with this. In this resource download below!, we focus on what technology tools exist to address social non-medical needs identified through screening. For those patients with high need, the standard response is likely to be health center-based and intensive. For example, patients with high need may be provided with 1 intensive case management, social workers, and referral coordinators; 2 direct assistance with connecting to resources; 3 follow up with external providers; and 4 regular in-person follow-up visits. This is likely to take up the majority of available staff capacity. However, gathering social determinants of health information may also point to other needs among patients with more moderate needs or in a broader array of areas such as paying utilities or legal services. Given staff capacity and resource limitations, as well as patient preferences, those patients may require another way to be connected with appropriate community resources. It is important that any approaches used allow for tracking and follow-up, as well as provide information about community service capacity. The tools in the case study below including Aunt Bertha, Now Pow, and 211 Community Information Exchange support this process by facilitating connection with community resources and needed follow-up, partially answering the question We collected social determinant of health data, now what do we do? Download the resource below for full case studies and lessons learned from using Aunt Bertha, 211 Community Information Exchange, and other new tools for connecting patients with community resources! More Details...

Using Health Center Needs Assessments To Address Legal Needs (2016). Resource Type: Publication. Description: This fact sheet outlines how health centers can use community needs assessments to understand and meet their patients’ health-harming civil legal needs. More Details...

Using Data to Manage Population Health Under Risk-Based Contracts: A background on what you need and how to use it (2017). Resource Type: Publication. Description: This resource will equip health center stakeholders with the understanding of what data-related capacity is needed to succeed under risk-based payment models.   This brief walks health centers through three key questions related to using data to succeed under risk-based contracts: 1 What data do I need and how do I get it?  2  How should I analyze the data? and 3 How should I use the data to manage quality and cost? Understanding the answers to these questions assists health centers in understanding the data-related capacities needed to participate successfully in risk-bearing payment models. Download the brief below! More Details...

Transportation Quality Improvement Toolkit (2016). Resource Type: Toolkit. Description: HOP's toolkit titled “Transportation and Health Access: A Quality Improvement Toolkit" is an easy-to-use, practical guide to assist health centers with assessing the scope of the problem and finding solutions to missed medical appointments due to transportation barriers. The toolkit guides the user through the two key phases of the quality improvement process: Needs Assessment and Plan-Do-Study-Act (PDSA) cycle, a continuous quality improvement process. Each section contains an overview of the concepts and sample tools. The tools are designed to be a starting point, and can be customized as needed to align with the specific context and resources of each health center. More Details...

Transportation and Health Access Infobook (2016). Resource Type: Publication. Description: Since 2000, Health Outreach Partners (HOP) has conducted bi-annual national needs assessments of community health centers serving underserved populations. The findings have consistently demonstrated that transportation is a top barrier to health care access. This infobook provides a general introduction to the topic of transportation as a barrier to health care access in the United States. The material is drawn from interviews, case studies, and reviews of existing literature. Although geared towards community health centers, it is relevant to all health care providers. More Details...

The Role of Enabling Services in Patient-Centered Medical Homes (2010). Resource Type: Publication. Description: This fact sheet highlights enabling services (ES) as a critical factor that should be included in the Patient-Centered Medical Home (PCMH) model. It describes the important role health centers play in the Asian American, Native Hawaiian, and Pacific Islander (AA&NHPI) community and the challenges they face in providing care for populations with many nationalities and languages. It also includes recommendation for how health centers serving the PCMH model can incorporate these services and improve care. More Details...

Successful Practices in Accountable Care: Centerprise, Inc. (2017). Resource Type: Publication. Description: This paper provides health centers with an overview of lessons learned implementing population health in care settings. More Details...

Strategies for Providing Health Care for Frequent Users in Rural Communities: Rural Communities Build Health and Housing Partnerships (2016). Resource Type: Archived Webinar. Description: Access to healthcare and other critical services in rural communities is impacted by various factors from travel distances between locations to limited financial resources and provider capacity. Community health centers, supportive housing and social service providers and other health system providers have a great deal to benefit from partnerships that address Social Determinants of Health and enable them to share information, coordinate successful strategies and leverage resources. More Details...

Strategic Guidance for Health and Housing Partnerships: Step by Step Strategies for Health and Housing Partnerships (2015). Resource Type: Publication. Description: This indepth resource guide explores the importance and value of partnering with supportive housing providers, partner perspectives and goals, how to assess your organization's and your partner organization's readiness, and how to make partnerships last. More Details...

SDOH Academy Pilot Resources (n.a.). Resource Type: Online Self-Paced Learning Modules. Description: No annotation provided by the authoring organization. More Details...

Results of Population Health Analytics/ Data Integration Survey: PCA/ HCCN Experiences Assessing and/ or Implementing Systems (2017). Resource Type: Publication. Description: 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. HITEQ conducted an anonymous survey of population health analytic and data integration system needs and impressions among Primary Care Associations and Health Center Controlled Networks 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. This piece reflects the aggregated responses of the 26 responding organizations that chose to participate through a call for responses to PCAs/ HCCNs. Responses are anonymous, are shared as they were provided with minimal editing, and reflect the views and experiences of the respondent(s) only. If you have experiences to add, please respond to the survey or email us! The survey results include: Number of respondents reviewing each system Ratings on selected functions Comments provided related to selected functions Data storage and management for each system Access to raw data downloads Features most important when assessing/ selecting a system Other priorities Reasons for making selection, vendor specific Reasons for making selection, general Three main lessons you’d like to pass on as a result of this experience General Comments Consider using this tool to help guide your thinking as to what questions you might ask vendors as well as what features you may want to see demonstrated if you are considering selecting a system of this type. The HITEQ Center does not endorse any systems or vendors, and has not validated any of the responses provided. More Details...

Recommendations for Promotores(as) de Salud and Language Access Services at your Health Center (2020). Resource Type: Publication. Description: As both skilled professionals and members of the community, Promotores(as) are in a unique position to address health issues in any community. One role that Promotores(as) often fill is as an interpreter between patients and clinical staff. Promotores(as) are well-positioned to act as the liaison, both linguistically and culturally. By helping patients better understand their clinical provider’s care instructions, Promotores(as) can build a stronger bond of trust between the patient and clinician and encourage better adherence to follow-up treatment. More Details...

Promising Practices for Health Centers Serving Youth Experiencing Homelessness: Profiles in Health and Housing Partnerships Serving Young Adults (2018). Resource Type: Publication. Description: This case study profiles Health Centers engaging and serving youth facing the challenges of homelessness on the street and in community based housing More Details...

Project Power (n.a.). Resource Type: Toolkit. Description: Project Power is designed for boys and girls, ages 8 -16 with multiple risk factors for developing type 2 diabetes. More Details...

Population Health Management, Social Determinants of Health and How These Fit: The relationship between population health management and social determinants of health (2016). Resource Type: Publication. Description: This is a 21-slide module presenting an introduction to the concept of and relationship between population health management and social determinants of health beginning with current definitions, a brief history of along with the evolution of the field. This is a 21-slide module presenting an introduction to the concept of and relationship between population health management and social determinants of health beginning with current definitions, a brief history of along with the evolution of the field. A comprehensive model for the relationship among the social determinants of health and outcomes of population health is also included. More Details...

Partnering with Public Housing Authorities to Increase Resident Participation (2013). Resource Type: Toolkit. Description: No annotation provided by the authoring organization. More Details...

On the Ground Floor: Housing First Frequent Users of Health System Initiative: Common Challenges and Promising Community Practices (2017). Resource Type: Publication. Description: On the ground communities are building the right partnerships to address the housing and health service needs of their frequent users of crisis care systems. This report summarizes the discussions and lessons learned from four communities implementing health and housing partnerships for frequent users. More Details...

Navigating the CMS Emergency Preparedness Rule: A Step-by-Step Guide (2018). Resource Type: Publication. Description: This guide serves to help health centers navigate CMS' requirements. More Details...

Medication-Assisted Treatment: Buprenorphine in the HCH Community (2016). Resource Type: Publication. Description: This policy brief discusses buprenorphine treatment in the HCH environment, identifying challenges to treatment and recommendations for both clinical practice and public policy change needed to increase access to care. It is also the broader hope that the information in this policy brief can help prevent further deaths from opioid addiction, inform clinical training needs, influence how communities respond to addiction treatment, improve public health, and promote a more seamless integration of addiction treatment with primary care services. More Details...

Measuring Population Health Management Return on Investment: A methodology to calculate ROI (Return on Investment) using a Matrix Tool (2017). Resource Type: Publication. Description: There is a great deal of interest among health centers, Primary Care Associations PCAs, and Health Center Controlled Networks HCCNs in the advantages associated with investing in Population Health Management electronic platforms. Measuring specific and quantifiable returns clarifies the benefits and supports consistent understanding among stakeholders of the value of PHM. There is a great deal of interest among health centers, Primary Care Associations PCAs, and Health Center Controlled Networks HCCNs in the advantages associated with investing in Population Health Management PHM electronic platforms.  Measuring specific and quantifiable returns clarifies the benefits and supports consistent understanding among stakeholders of the value of PHM. Available below, the PDF document titled Measuring Population Health Management Return on Investment outlines a conceptual process for measurement of ROI of a population health management system offered at the network level. What is presented here could also be used a starting point for developing an ROI analysis at the organizational level. The companion tool, an Excel file titled PHM ROI Matrix Tool, provides recommendations for measurement for different stages of PHM implementation and an ROI calculator. Download both of these resources below. These resources were created in partnership with Michigan Primary Care Association and Mark S. Rivera of Managed Care Consulting Inc./MCC Analytics, and HITEQ thanks both for their time, insight, and energy. More Details...

Improving Diabetes Outcomes: Curated Expert Guidance, Tools, and Resources (2017). Resource Type: Publication. Description: According to 2016 UDS data, an estimated 14.3% of Federally Qualified Health Center patients nationwide have diabetes. Of these 2 million plus patients living with diabetes, approximately 32% have uncontrolled diabetes, with HbA1c equal to or above 9% or have had no test in the prior year. These statistics bring forth the need for improvement in the care of diabetes; several resources and research outcomes are profiled here with specific takeaways for health centers. As of CDC's 2017 National Diabetes Statistics Report, 30.3 million people, or 9.4% of the total U.S. population, have diabetes. Of these 30.3 million, only 23.1 million are diagnosed - while the other estimated 7.2 million are undiagnosed. Additionally, more than 1 in 3 adults or 84.1 million people in the U.S. have prediabetes. Among adults age 65 and older, nearly half have prediabetes. More Details...

ICD-10 Z-Codes for Social Determinants of Health: A quick reference guide for providers and health care leaders (2017). Resource Type: Publication. Description: This resource will equip health center stakeholders with the understanding of how standardized social determinants of health (SDoH) data can be used and which ICD10 z-codes are pertinent as a standardized SDoH data set. This resource describes ways standardized social determinant of health (SDoH) data can be used and provides a quick reference guide to which ICD-10 codes can help document standardized SDoH data.  Download here or below. More Details...

HITEQ-Social-Determinants-Data-Infographic-2017: Coding Social Determinants of Health (SDH) for Optimizing Value (2017). Resource Type: Other. Description: SDH coding is important for clinical management and outcomes reporting for payment reform and value based payment (particularly capitate payment), as well as other policy work. SDH coding begins with care providers, who often may need to understand how these data can be used to benefit not only the patient they are serving but also the broader population served by the organization. More Details...

Helping Residents in Public Housing Understand the Affordable Care Act (n.a.). Resource Type: Publication. Description: No annotation provided by the authoring organization. More Details...

Health Outcomes and Data Measures for Supportive Housing and Health Centers: A Quick (Data) Guide for Health and Housing Partnerships (2017). Resource Type: Publication. Description: Both health and housing providers are tracking data elements and outcomes for a similar vulnerable populations. This resource guide highlights the common data elements currently being tracked, and opportunities to learn from multi-sector partners More Details...

Health Effects of Excessive Heat on Underserved Populations (n.a.). Resource Type: Archived Webinar. Description: No annotation provided by the authoring organization. More Details...

Health Centers Strategies for Diabetes Screening and Prevention for Children, Adults, and the Elderly webinar (2018). Resource Type: Archived Webinar. Description: This webinar explores diabetes prevention and care strategies across the lifespan. Presenters discuss standards of care in the screening and prevention for children, adults, and the elderly, sharing experiences from the field. Case examples of successful diabetes prevention programs, adult clinical treatment, and geriatrics care focused on vulnerable populations of children and adults of all ages are provided. More Details...

Health Centers as Assets in their Community: Assessing Your Environment (2018). Resource Type: Archived Webinar. Description: This session is designed to provide attendees with a tour of the range of research resources available for health centers to assess market opportunities (many of them are free for all to use). We will review techniques for how to determine the size and location of the low-income, uninsured and under-served population, estimate the level of unmet need, and translate this information into workforce needs and a preliminary capital project budget. This session will also take a broader view in exploring how to determine where community gaps are within a service area with respect to the Social Determinants of Health, identifying types of assets in a community that support health and wellness. More Details...

Health Centers and Coordinated Entry: How and Why Health Centers Can Benefit When They Engage with Local Homeless Systems (2017). Resource Type: Publication. Description: Coordinated Entry is just one of many federal housing policies that greatly impact the work of health centers. This series translates federal housing policies to help health centers understand the impact and how to coordinate and adapt programming to create the most beneficial outcomes for clients. More Details...

Health Center Value Proposition Template: The Value of Health Centers in Assisting their Community to Meet the Triple Aim (2016). Resource Type: Publication. Description: This customizable document uses health center data to support them in demonstrating their value to potential partners and key stakeholders. The document provides evidence for how health centers align with the Triple Aim. Health centers can fill in and customize the value proposition template to demonstrate the value of their primary care services and care model in providing high quality, cost-effective care to those most in need.  The template is structured around the three tenants of the Triple Aim: 1. Improving population health through economic and job growth; addressing social determinants of health; and providing high quality care through a health home model, quality outcomes and implementation of health information technology. 2. Improving patient experience by providing care that is responsive to the needs and realities of the patient population, including patient portals, non-traditional hours and timely appointments. 3. Reducing the per capita cost of health care by engaging in payment reform efforts and providing high-quality care at a low cost. Download the template to create your value proposition below. More Details...

Health and Housing Partnerships: Making the Work: Online Tutorial: Step by Step Strategies for Health and Housing Partnerships (2017). Resource Type: Online Self-Paced Learning Modules. Description: This self-paced online class explores the importance and value of partnering with supportive housing providers, partner perspectives and goals, how to assess your organization and your partner organization, and how to make partnerships last. More Details...

Health and Housing Partnerships for Older Adults: Aging in Place in Supportive Housing (2017). Resource Type: Publication. Description: This case study profiles Health Centers serving aging and vulnerable populations in their communities More Details...

Health and Housing Partnership Profiles - Washtenaw MI: Case Study on Frequent User Intiatives in Washtenaw MI (2016). Resource Type: Publication. Description: This Profile focuses on Washtenaw MI, and the multiple health sector providers joined with local government and housing providers to target resources and services for the most vulnerable in the community as part of a series of real Health Center Case Studies engaged in effective Frequent User Initiatives in communities around the country. More Details...

Health and Housing Partnership Profiles - Orlando FL: Case Study on Frequent User Intiatives in Orlando FL (2016). Resource Type: Publication. Description: This Profile focuses on Orlando FL, and Orange Blossom Family Health - the Healthcare for Homeless Center in Orlando as part of a series of real Health Center Case Studies engaged in effective Frequent User Initiatives in communities around the country. More Details...

Health and Housing Partnership Profiles - Los Angeles CA: Case Study on Frequent User Intiatives in Los Angeles CA (2015). Resource Type: Publication. Description: This Profile focuses on Los Angeles CA and a multi-sector partnership to identify, house and provide services to the most vulnerable in the community as part of a series of real Health Center Case Studies engaged in effective Frequent User Initiatives in communities around the country. More Details...

Health and Housing Partnership Profiles - Houston TX: Case Study on Frequent User Intiatives in Houston TX, (2016). Resource Type: Publication. Description: This Profile focuses on Houston TX and Healthcare for Homeless - Houston as part of a series of real Health Center Case Studies engaged in effective Frequent User Initiatives in communities around the country. More Details...

From Zero to 60: Medical-Legal Partnership Fundamentals & Strategies (2017). Resource Type: Archived Webinar. Description: This national webinar features the experiences of 3 different health center based MLP programs, and highlights basic operational and implementation strategies. More Details...

Finding Resources for Health and Housing Partnerships: Partnerships to Create New Funding Mechanisms (2016). Resource Type: Archived Webinar. Description: Looking for resources to support your health center partnerships? This webinar highlights funding sources to seek out to support health partnerships with housing providers in their community More Details...

Financial Responsibility Tool (2017). Resource Type: Publication. Description: This resource is a low-literacy tool for all Migrant & Community Health Centers on your patients' financial responsibility. The tool covers how and what patients should expect to pay as well as an easy-to-understand infographic on the Sliding Fee Scale. More Details...

Engaging Youth Experiencing Homelessness (2016). Resource Type: Publication. Description: The large numbers of young people experiencing homelessness in the United States each year are at significant risk of diseases, injuries and developmental delays that can impair their functioning, potentially for their entire lives. Moreover, engaging them in services can be difficult for a variety of legal, psychological, and practical reasons. Wanting to minimize the risks faced by these young people, to improve their health status, and to help them avoid a lifetime of homelessness, Health Care for the Homeless (HCH) and other service providers have developed various strategies for engaging homeless youth in systems of care. This publication describes practices and services that HCH agencies have found to be helpful in engaging youth experiencing homelessness. More Details...

Enabling Services at Community Health Centers (2010). Resource Type: Publication. Description: This report introduces the important role enabling services (ES) play in the delivery of high quality care for medically underserved Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs). It details the high utilization of such services and the impact they have on patients' health outcomes. It concludes with recommendations for establishing a nationally recognized standard for ES data collection and utilization, integrating ES into the Patient-Centered Medical Home (PCMH) model, and funding to sustain and ensure quality services.