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Introduction. Use this page to quickly find all resources from the Clearinghouse database on Value-Based Health Care Transformation.

Background. Value-based health care is an emerging health care delivery model that ties payments to patient outcomes. The Clearinghouse’s Value-based Health Care Transformation topic area covers related issues including Enabling Services (ES), Patient-Centered Health Outcomes, Patient Engagement, Programs and Services, and Value-Based Payment.

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Results for: Topic Area = Value Based Health Care Transformation

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Centering the Nurse Home Visitor Client Experience During the COVID-19 Pandemic (2021). Resource Type: Archived Webinar. Description: The COVID-19 pandemic has upended virtually every facet of life. By necessity, healthcare organizations have limited or restricted in-person care to reduce the transmission of SARS-CoV-2. Unfortunately, this has kept many consumers from accessing timely healthcare. More Details...

Just Breathe (2021). Resource Type: Publication. Description: This collection of wellness and recovery resources has been designed for survivors of domestic violence to track their progress and develop techniques for calming oneself and moving forward in the healing process. More Details...

Strategies for Supporting Health Center Patients Experiencing Food Insecurity (2021). Resource Type: Publication. Description: Food insecurity has doubled since the onset of the COVID-19 pandemic in March 2020, and has tripled among families with children. Not having enough access to food is a key contributor to negative health outcomes for adults and children alike, and it is important now more than ever for health centers to identify and support patients who are experiencing food insecurity. This resource is designed to support health center efforts to identify and assist patients who are experiencing food insecurity. It outlines key considerations around integrating social determinants of health (SDoH)-related screening and intervention into the electronic health record (EHR) workflow, highlights standardized screening tools and data elements to monitor the prevalence of food insecurity among patients, and describes several strategies to meet food-related needs. The downloadable guide, available in the Documents to Download section below, is split into the following sections, each of which draws on foundational work from health centers and national partners: Integrate your screening strategy into your EHR workflow-- several case studies are included Select a standardized tool to identify food insecurity-- several tools with their related EHR integration and workflow considerations are outlined Monitoring food insecurity among patients-- tips about coding and dashboarding are provided Connecting patients to available resources More Details...

Isolation & Loneliness: The Digital Transformation in Social Determinants of Health (2020). Resource Type: Archived Webinar. Description: The third webinar in the Weitzman Institute\'s Path Forward \"The Digital Transformation in Social Determinants of Health\" fall series focusing on addressing isolation and loneliness as an important public health issue. The content expert for the webinar is Gretchen Alkema, PhD; Vice President of Policy and Communications, The SCAN Foundation. Presenters for the webinar includes: Andrew Parker, Founder & CEO of Papa; Cindy Jordan, Founder & CEO & Christina Myren; Chief Operating Officer of Pyx Health; and Ashwin Patel, Co-Founder & CEO of InquisitHealth. More Details...

Using AI, Data, and Tech to Move from Screening to Solving for Social Needs: The Digital Transformation in Social Determinants of Health (2020). Resource Type: Archived Webinar. Description: The first of five webinars in the Weitzman Institute\'s Path Forward \"The Digital Transformation in Social Determinants of Health\" fall series focusing on addressing why SDoH matters and innovations in using AI, data, and tech to move from screening to solving for social needs. Panelists for this session include: Dr. Paul Grundy, MD, MPH, FACOEM, FACPM; Chief Transformation Officer, Innovaccer, Margaret Flinter, PhD, APRN, FNP-c, FAAN, FAANP, Senior Vice President and Clinical Director, Community Health Center, Inc., April Joy Damian, PhD, MSc, CHPM, PMP; Associate Director, Weitzman Institute, Nancy Lopez, PhD, Director & Co-founder, Institute for the Study of “Race” & Social Justice, University of New Mexico, and David Kulick, MPH, Co-founder, Adaptation Health More Details...

Predictive Analytics, Assessing Vulnerability, and Community Referrals: The Digital Transformation in Social Determinants of Health: Predictive Analytics, Assessing Vulnerability & Community Referrals (2020). Resource Type: Archived Webinar. Description: The second webinar in the Weitzman Institute\'s Path Forward \"The Digital Transformation in Social Determinants of Health\" series focusing on predictive analytics, assessing vulnerability, and community referrals. Panelists include Kurt Waltenbaugh; Founder & CEO of Carrot Health, John Showalter; Chief Product Officer at Jvion, Erine Gray; Founder & CEO of Aunt Bertha, and Ruben Amarasingham; Founder & CEO of Pieces Tech. More Details...

The Path Forward: Re-Imagining Primary Care During and Beyond the Pandemic (2020). Resource Type: Archived Webinar. Description: As the nation struggles with the dual pandemics of COVID-19 and racism, the moment is upon us to deeply examine and reshape the primary care delivery system for underserved communities. In this webinar, leadership of the Community Health Center, Inc. and its Weitzman Institute will lay out a road map for the new Path Forward. We invite health center and safety net providers, staff, consumer leaders and others to join the conversation and contribute their expertise, perspective and ideas. More Details...

Woven with Elders: Pacific Islander Vaccine Toolkit (2021). Resource Type: Toolkit. Description: The Pacific Islander Center of Primary Care Excellence (PI-CoPCE) was established to improve the health of Pacific Islanders (PIs) in the United States and U.S. Pacific through primary care support, research, workforce development, and community initiatives. More Details...

The Path Forward: Collaboration & Resources (2021). Resource Type: Archived Webinar. Description: The fourth of five webinars in the Weitzman Institute\'s Path Forward \"Moving from Screening to Solving for Social Needs\" series focusing on forging partnerships and collaboration among a wide spectrum of stakeholders to address the adverse social determinants of health with presenters Taylor Justice; Co-Founder & President, Unite Us, Sue Birch; Director, Washington State Health Care Authority, and Laura Sankey; Principal, Inspired Perspectives, and Nationally Recognized SDOH Expert. More Details...

The Path Forward Series Finale (2021). Resource Type: Archived Webinar. Description: The final webinar in the Path Forward \"Moving from Screening to Solving for Social Needs\" series wraps up by highlighting all of the webinars in the series, examining the role of community centers in addressing social determinants of health (SDOH), and ending with a call of action with presenters Margaret Flinter, PHD, APRN; Senior VP and Clinical Director, CHC, Inc., Trishan Panch, MD, MPH; Co-Founder, Wellframe, Co-Director – Applied AI for Healthcare, Harvard TH Chan School of Public Health, President Elect – Harvard TH Chan School of Public Health Alumni Association, and Yvette Highsmith-Francis, MBM; Vice President, Eastern Region, CHC, Inc. More Details...

The Path Forward on Social Determinants of Health: Safety: Advancing Community and Personal Safety (2021). Resource Type: Archived Webinar. Description: The second of five webinars in the Path Forward \"Moving from Screening to Solving for Social Needs\" series focusing on community and personal safety with presenters Tracy Nordstrom; Placemaker and Principal, Verve, Dr. Mariela Alfonzo; Founder& CEO, State of Place, Frode Kjersem; CEO, bSafe USA. More Details...

Evolving Care Team Models, Strategies to Assess Provider Satisfaction, and Addressing Burnout (2021). Resource Type: Archived Webinar. Description: This Project ECHO Webinar was part of a three-part webinars series on provider burnout and satisfaction during the COVID-19 vaccination rollout. This session addresses the topic of emerging models of team-based care in the COVID and post COVID environment. This COVID-19 ECHO session is a collaboration with HRSA\'s National Health Center Training and Technical Assistance Partners on Team-Based Care. More Details...

Staff Roles, Responsibilities, and Training Throughout the Vaccination Cycle (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...

Essential Policies, Procedures, and Roles in Managing, Protecting, and Administering Your Vaccine Supply (2001). 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...

Ten Strategies for Creating Inclusive Health Care Environments for LGBTQIA+ People (2021) (2021). Resource Type: Publication. Description: Creating welcoming, inclusive, and affirming health care environments is critical for increasing access to care for LGBTQIA+ people. This guide presents ten strategies every health care organization can do to become more affirming and welcoming for LGBTQIA+ patients and staff and sets a foundation for comprehensive organizational change. 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...

Hepatitis C Virus (HCV) Cost Calculator (2020). Resource Type: Toolkit. Description: NNCC’s HCV Cost Calculator is an interactive tool designed to evaluate the costs and benefits of Standard vs Enhanced HCV Care. The HCV Cost Calculator uses a numerical value-based model of health center staff training, screening, and treatment regimen to estimate the cost-benefit comparison and return on investment (ROI) to the health center. More Details...

Diabetes, Heart Disease, and LGBTQIA+ Populations (2020). Resource Type: Archived Webinar. Description: Dr. Alex Gonzalez of Fenway Health  and Katherine Overton of the American Heart Association discuss diabetes and heart disease in LGBTQIA+ populations. 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...

Guide to Improving Care Processes and Outcomes in Health Centers: An approach to quality improvement (2016). Resource Type: Publication. Description: The quality improvement QI approach outlined in this Guide can be used to augment current QI approaches used in your health center, or can serve as a placeholder QI methodology when there isn’t already a robust QI process in place. It provides a framework and tools for documenting, analyzing, sharing and improving key workflows and information flows that drive performance on high-stakes care performance measures, and related improvement imperatives. This webpage provides strategies and tools that health centers and their partners can use to enhance care processes and outcomes targeted for improvement, such as hypertension and diabetes control, preventive care, and many others.   This webpage provides strategies and tools that health centers and their partners can use to enhance care processes and outcomes targeted for improvement, such as hypertension and diabetes control, preventive care, and many others. For authorship and acknowledgement for this Guide, see the bottom of this guide. The quality improvement QI approach outlined in this Guide can be used to augment current QI approaches used in your health center, or can serve as a placeholder QI methodology when there isn’t already a robust QI process in place. The approach provides a framework and tools for documenting, analyzing, sharing and improving key workflows and information flows that drive performance on high-stakes care performance measures, and related improvement imperatives.  The diagram to the left illustrates the data-driven, health IT-enabled continuous quality improvement approach that this Guide supports.  For an overview of the information contained herein access this recorded webinar and companion materials including transcript and slides for reference.     Background to Guide Guide Context and Approach This section includes guidance on leveraging Health IT to improve quality and clinical performance including data validation tools, Clinical Decision Support Quality Improvement worksheets, and change packages for recommended approaches related to various quality of care measures. Read More...   The diagram below illustrates the Guide’s focus on helping health centers adapt to the intensifying performance improvement imperatives they face pyramid tip. The Guide does this by providing strategies and tools to help analyze and improve critical workflows and information flows layers beneath the pyramid tip. For an introduction to the Guide that was presented as part of a webinar, see here the pertinent discussion is between these times/markers on the recording: 43:46-58:44     Audience The strategies and tools in this Guide are designed for quality, clinical and other health center staff, and health center partners that support quality improvement efforts. Read More... Everyone in a health center has a stake in successful quality improvement, and many different staff roles might be the first to encounter this Guide. For initial review, roles including QI/clinical/data/operations team members or leads are likely most appropriate. To drive substantial improvements, these tools and strategies should then be shared and used more widely with pertinent health center team members responsible for the organization’s clinical, operational and other activities key to successful QI. A QI team is typically the driving force behind the cross-stakeholder work outlined in this Guide. For more on building QI teams, see here.   Various organizations that support or depend on information from QI efforts within health centers can also become better QI partners by understanding and applying the strategies and tools in this Guide. These partners include:   Support organizations such as HCCNs, PCAs, payers and others   Organizations that supply health centers with technology that play a critical QI role, such as EHR and population health software vendors    Why Using this Guide is Important for Health Centers Quality improvement has traditionally been a core health center activity as health centers try to continually maximize value and efficiency. Dramatic healthcare payment reforms, increasingly tying payment to QI efforts and results, make effective QI a business imperative for all provider organizations. Wherever your organization is on the QI journey – from beginning through highly sophisticated – this Guide uses tools such as the CDS/QI Worksheets -- see under 'Document/ Analyze Flows; Identify Improvements' and strategies such as the CDS 5 Rights Framework that can enhance your QI efforts and results. Read More... Payment reforms seek to transform healthcare to achieve 3 key goals often referred to as the ‘Triple Aim’ or ‘Three-part Aim’:   Better care for individuals   Better health for populations   Lower cost   Key stakeholders assert that to achieve these goals, it’s important to also improve work life for clinicians and staff. Adding this dimension to the 3 goals above is referred to as the ‘Quadruple Aim.’ This shift to value-based payment is driven by both the public and private sector, and directly affects FQHC financial health. For example, the Merit-based Incentive Payment System is transforming Medicare by tying provider payments to performance on quality measures, clinical performance improvement activities, costs, and use of health IT. Medicaid and private payers are also driving transformation through increasing use of value and/or risk-based contracts that require successful QI.   Many health centers already use robust QI approaches such as those outlined in this quality improvement primer as part of UDS measure reporting and improvement efforts. Many likewise leverage powerful health IT capabilities such as population health management tools including disease/condition registries; EHR tools to enhance ordering, documentation and data review; and SMS texting with patients in this QI work. The drivers noted above, however, require increasingly sophisticated and effective approaches to health IT-enabled Quality Improvement health IT/QI. Other closely related terms include eCQI used by ONC and CMS and CDS-enabled QI CDS/QI, so those are terms referenced in some materials in this Guide as well.   The framework, strategies, and tools in this Guide can help your organization enhance its health IT/QI approach and results. In addition to the benefits this delivers in addressing payment drivers noted above, it can also improve staff satisfaction by streamlining care workflows, improve health center business strength by avoiding duplicated efforts and decreasing costs, and improve patient satisfaction by meeting their care needs more efficiently and effectively. How to Use this Guide The next main section of this resource, Health IT-Enabled QI Guide Details provides a step-by-step approach and tools for analyzing and enhancing care processes targeted for outcome improvement. The steps are outlined in the pathway under the first heading in that section, Approach to health IT-enabled QI. Read More... The Essential CDS/QI Worksheet is a core resource for analyzing and improving target-focused care. A preliminary workflow analysis and enhancement brainstorming exercise can be accomplished in as little as an hour by one or more health center staff reviewing the tutorial and using this worksheet. More comprehensive QI projects addressing all the steps in the pathway typically take up to a year or longer. In any case, the QI work should be a collaborative process involving all stakeholders within the health center, and ideally key partners as well such as the HCCN or PCA working with the health center, and their EHR and population health software vendors. Scanning these evidence-based strategies and tools will give health centers and their partners a sense for whether/how they can augment your current QI work. Users can then apply these approaches and resources with their team to the depth that would be most valuable and feasible given available time and resources. For a “quick win” exercise to identify potential high-yield, target-focused care process improvement opportunities, see this presentation Health IT Enabled QI: A Guide to Improvement. For additional ideas on introductory QI exercises, see the brief slide set, Five Minutes of Quality Improvement: Tackling Small QI Tasks. Contact the HITEQ Center for support on implementing the QI approach in this Guide.   Strategies and tools from this Guide in action:   CDS Learning Session ‘Quick Win’ Exercise: Sixteen community health centers in New Orleans conducted a valuable ‘Quick Win’ exercise using an earlier version of the Essential CDS/QI worksheet see here for further details about this exercise and results. In this activity, small teams from each health center e.g., a clinician and administrator were given a 20-minute overview of several key health IT/QI concepts and tools outlined in this Guide the broad CDS definition, CDS 5 Rights framework, and an earlier version of the CDS/QI Worksheet, each of which is explained later in this guide.   Immediately following, for just 20 minutes, each team independently used an enlarged version of the Essential CDS/QI Worksheet on a flip chart to document key workflows and information flows for their improvement target e.g., lipid or diabetes control. During this time, they also brainstormed refinements to one or more of the CDS 5 Rights “who, what, when, where, how” dimensions.   During the report-out following this brainstorming, health centers noted excitement about trying these enhancements to improve care processes and outcomes related to their target.   Using the Guide for Yearlong, Target Focused QI: Other QI projects have used the strategies and tools outlined in this Guide in yearlong, target focused QI efforts and have realized benefits for quality improvement and care processes, and increasingly in outcomes. In many cases these efforts involved collaboration with HCCNs and/or HIE/EHR/population management software vendors. These initiatives include:   A network of health centers in CA working on blood pressure control. The lead health center in this project, Petaluma Health Center, is a 2015 Million Hearts Hypertension Control Champion. View project report slides.   Improving blood pressure and diabetes in control in Trenton, NJ that included a health center among the participants. View project report slides .   Health centers in several states working on hypertension diagnosis and management several of which are achieving aggressive blood pressure improvement targets. Link to project overview.   Health IT-Enabled QI Guide Details Approach to Health IT-enabled QI The outline depicted in the figure below provides a step-by-step approach to analyzing and enhancing care processes targeted for outcome improvement. The sections below provide guidance and tools on addressing each of these steps. Read More...   Check/ Reinforce Foundations Successful health IT/QI efforts require a firm foundation of people, process, and technology elements. Read More... Cultivate a shared commitment within your team to improving care delivery and results, including fully leveraging health IT capabilities. Successful QI efforts deliver a ‘win-win-win’ for patients and their care teams, as well as broader organizational goals. This infographic and report examines characteristics of health centers that have achieved high clinical, financial and operational performance.     Ensure that key foundations for successful QI efforts are in place. For example, leadership and team support; stable well-utilized health IT systems such as EHR, population management software; bandwidth and capacity for the QI work; and shared understanding about QI goals and processes.  For some specific resources around ensuring key foundations, see here for Motivating Factors for Engaging in Health IT-enabled QI, and Engaging the Data Creators.  Also, see here for A Buyer’s Guide to Business Intelligence Tools.  Here is a tool to assess analytics capability in health centers, that also provides insights into the nuance of working with data and building a data-driven culture. A brief video introduction to using this tool is here.   Ensure access to and validate data that will underpin the QI efforts. For example, ensure that EHR and/or population management software can deliver needed data and reports, and produce the same values for targeted performance measures and related data as manual review/calculation. See here for questions to consider to help determine if you are fully utilizing your EHR capabilities for population management, and if additional tools are needed. This checklist can help with data validation and interpretation a webinar that includes an introduction to this checklist is here, and the pertinent discussion is between these times/markers on the recording: 8:15- 43:45. See here for a basic auditing tool Excel Template for data reports, and a case study on data validation.   Identify and address barriers to collaboration on effective process improvement such as stakeholder conflicts or conflicting goals among all concerned, including providers, care delivery and quality staff, partners e.g., health IT vendors, and patients.   Layer the approach and tools outlined below onto your general QI methodology, as well as any current target-focused QI activities. If no QI framework is in place, consider using the approach outlined in this Guide as a starting point, and build that out further through options such as those provided in the primer, Continuous Quality Improvement CQI Strategies to Optimize your Practice. Understand Health IT-enabled QI Everyone participating in the QI work should have a shared understanding of key definitions e.g., CDS, frameworks e.g., CDS 5 Rights, strategies e.g., the QI process outlined under the Implement and Evaluate Changes heading., tools e.g., Essential CDS/QI Worksheet, and key QI project success factors.   Read More... ‘Clinical Decision Support’ CDS is a key underpinning for the QI approach outlined in this Guide, but its meaning here might be different than what you have in mind especially if ‘alert’ figures prominently in your definition. In this Guide, CDS is defined as a process for improving health-related decisions and actions with pertinent knowledge and patient information to enhance health and care delivery. Under this definition, CDS is about supporting care decisions and actions, ideally in a manner that makes the appropriate decisions and actions the easy ones to execute. That is, facilitating workflow not interrupting it – as alerts often do. There are many different ways to provide this support e.g., CDS intervention types. See the CMS CDS tipsheet page for more details, including example CDS intervention types e.g., order sets, focused patient data summaries, documentation templates.   The CDS 5 Rights framework is a best practice QI approach recommended by CMS in the tipsheet above to support decisions and actions that drive performance targeted for improvement. It asserts that optimizing care processes and outcomes requires getting the right information to the right people in the right formats through the right channels at the right times see figure below. The tools and approaches outlined in this Guide help organizations implement this framework and enhance the contributions, experience and results for those involved in care delivery.   The Essential CDS/QI Worksheet see excerpt images below is a core health IT/ QI tool best used for initial efforts to map care processes and reveal potential enhancements. That is, to document and analyze target-focused information flows and workflows, and to brainstorm improvement opportunities see figure with excerpts from this worksheet below. The tutorial that follows provides guidance and examples on how the worksheet can be used. to streamline and enhance care processes. The Enhanced CDS/QI Worksheet,  pointed to below under the bullet titled 'For a deeper dive into health IT/ QI Foundations', is a more robust but more complicated tool for those already skilled in using the Essential CDS/QI Worksheet View the Tutorial on how to use the Essential CDS/QI Worksheet   See a completed Outpatient Essential CDS/QI Worksheet Example that uses this tool to illustrate the workflows and information flows that produced very high levels of blood pressure control in a small practice: Ellsworth Hypertension QI Case Study Note: this example used an earlier version of the Essential CDS/QI Worksheet that did not contain the ‘Foundational Activities’ section. This case study was originally developed for ONC and is also posted on here on healthit.gov. Attend to key QI project success factors:   Focus on People, Process, and Technology in that order, recognizing that engaging everyone involved is critical for success.     Focus on ‘the most important things’ when selecting improvement targets, opportunities to enhance care processes for the target, and activities to ensure successful implementation of those process changes.     QI activities involve a chain of stakeholders including health center QI leads, clinicians and staff, and ultimately patients. As the QI project unfolds and each of these groups is touched by the effort, seek to escalate engagement, insights, and momentum toward goals. For a deeper dive into health IT/QI foundations, consider these resources:   Tasks and Key Lessons from each chapter in “Improving Outcomes with Clinical Decision Support, and Implementer’s Guide, 2nd Edition.” These bulleted lists provide detailed guidance on successful CDS-enabled QI programs and interventions.   Enhanced CDS/QI Worksheet: Similar in concept to Essential version, but with additional space to document/review optimal care activities for the target, and the individual CDS 5 Rights dimensions for the current state. Consider using only after you are comfortable with the Essential CDS/QI Worksheet version Note: this example used an earlier version of the Enhanced CDS/QI Worksheet that did not contain the 'Foundational Activities' section.   View the Tutorial on how to use this Enhanced Worksheet [download the PDF and run locally for best results].   See a completed Outpatient Example: CHC Inc. hypertension QI case study   White papers and guides on HIT-CDS/QI:   Qualis Health: Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety   AHRQ: Using Health Information Technology to Support Quality Improvement in Primary Care   ONC: How-To Guides for Clinical Decision Support CDS Implementation Select Targets; Initiate QI Project   Successful QI efforts typically require significant time, energy and resources, so it is important to choose targets where the return will warrant the investment. This requires a clear and accurate understanding of baseline performance on the target.   Read More... Consider targets associated with business imperatives, such as UDS reporting especially for conditions where the health center is under-performing, and value-based payment initiatives from the private sector and CMS e.g., the Quality Payment Program which is radically overhauling Medicare payments to clinicians, and related value/risk-based payment models for Medicaid. Seek QI synergies with pertinent health center initiatives such as PCMH recognition and HRSA Health Center Quality Improvement Grant Awards.   Examine local performance gaps and improvement opportunities when reviewing payment drivers noted above and selecting targets. See the figure below from the HIMSS guidebook on improving outcomes for examples of local factors to consider in selecting targets for quality improvement intervention. Image Reference: Osheroff JA, Teich JM, Levick D, et. al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, 2nd ed. Chicago: HIMSS. 2012.   Measure and understand your baseline performance on your targets. The CMS/ONC eCQI Resource Center has information about quality measure specifications for providers. The Checklist for Analyzing Performance Measure Data has detailed information about validating and interpreting these data. Document/Analyze Flows; Identify Improvements   A helpful QI adage is that “systems are perfectly designed to produce the results they deliver.” This truism highlights the importance of understanding current care processes that are driving sub-optimal performance on the targeted measure e.g., diabetes control, preventive care, use of expensive tests so they can be refined to deliver better results. The CDS/QI worksheet supports this analysis through a structured, broadly applicable framework for documenting, analyzing, sharing and improving target-focused care activities. Read More... Use the CDS/QI worksheet to help examine patient-specific and population management information flows and workflows, as well as foundational activities such as EHR configuration, policies, staff training, etc., that are producing sub-optimal performance on the target. For example, if the QI target is hypertension control, consider the current status of staff competency and training on measuring blood pressure appropriately foundational activities; registry use to identify and recall patients with poorly controlled blood pressure population management activities; and optimizing pre-visit huddles, order set use, and patient engagement/care plan adherence tools patient-specific supports.   Walk through the care process with special attention to the patient experience and document results in the Essential CDS/QI Worksheet.   Engage all care team members in the workflow/information flow and improvement analysis– including the patient, if possible.   If you are comfortable with the Essential CDS/QI Worksheet, consider using the Enhanced CDS/QI Worksheet instead of, or in addition to, the Essential Worksheet for a deeper dive into the ‘optimal state’ and the details of each CDS 5 Rights dimension.   Analyze this current state “what is?” to identify opportunities to improve target-focused information flow, workflow and results; i.e., to better address the CDS 5 Rights for the target. Document these potential enhancements in the CDS/QI Worksheet. Review the tutorial for the worksheet you are using i.e., essential vs. enhanced for guidance. For example, consider enhancements such as:   documentation templates, and related workflows for completing them, that make it easier to identify patient barriers to adherence with the care plan foundational activity;   text messages and/or personal calls to patients to decrease no-show rates patient-specific support, and   performance dashboards and related conversations to share target measure results with teams and clinicians as a springboard for brainstorming strategies to accelerate improvement population management activities.   Review evidence-based best care practices for the target “what should be”   Consider available best practice ‘change packages’ for the target:   For hypertension management, the CDC Hypertension Control Change Package presents change concepts, change ideas, and proven tools that outline ‘what should be’ best practices in categories that correspond to the categories on the CDS/QI Worksheets i.e., Foundation Activities, Population Management, and Patient-specific Supports and its subcomponents.   For detecting hypertension that may be ‘Hiding in Plain Sight’ in health centers and diagnosing hypertension so it can be managed appropriately to reduce heart attacks and strokes, see this similarly-structured “HIPS” change package.   For improving colorectal cancer screen rates as called for in the national "80% by 2018" campaign, see this similarly-structured change package   Examine other case examples and best practices for successful target-focused care strategies e.g., QI case studies published by ONC, and other resources:   Case examples on hypertension control:   Ellsworth Medical Clinic hypertension QI case study: narrative discussion and details presented in an earlier version of the Essential CDS/ QI Worksheet.   CHC, Inc.2 hypertension QI case study: narrative discussion and details presented in an earlier version of the Enhanced CDS/QI Worksheet. This study was originally developed for ONC and is also posted here on healthit.gov.   EHR Innovations for HTN Challenge results   Colorectal cancer screening recommendations for community health centers from the Oregon Primary Care Association and the National Colorectal Cancer Screening Roundtable    Case example on tobacco use screening and smoking cessation support at Miramont Family Medicine. This case study was originally developed for ONC and is also posted here on healthit.gov   Define potential workflow and information flow enhancements for the target “what could be here?” by combining ‘top down’ approaches i.e., starting from ‘what should be?’ best practices and ‘bottom up’ approaches i.e., improvement opportunities that emerge from the “what is?” analysis with stakeholders.   Prioritize identified enhancements to implement: Identify several enhancements that are most likely to deliver the greatest benefit in the shortest time with the least effort for initial implementation that is, use the “low hanging fruit” approach – see prioritization tools such as this Prioritization Matrix. Give special attention to changes that could yield strong benefits across multiple targets, or that appear especially promising for strengthening critical workflows and information flows e.g., related to patient engagement, registry use to identify and close care gaps, pre-visit planning, and efficiently executing evidence-based care plans. Implement & Evaluate Changes Implementing enhanced care processes requires that people e.g., health center clinicians, other staff, and patients do things differently. Formal change management approaches can help ensure that these changes are successful and that they produce desired results.   Read More... Use a QI methodology e.g., PDSA cycles to engage frontline staff and other key stakeholders in care processes and results to design, implement and evaluate the prioritized changes. Be sure to do this work with all the stakeholders and not to them i.e., seek and act on team members’ and patients’ input and feedback throughout the process. Be ready to modify patient care and quality improvement activities, CDS intervention details across any of the CDS 5 Rights dimensions, and other parameters if needed as improvement cycles unfold. Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results. Sample monitoring tools:   Worksheets from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring Results and Continuously Refining the Program in “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition” provided with permission from HIMSS   IHI PDSA Worksheet: http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx   Validate and analyze performance measure data to make sure that the results are accurate, and that the team understands what they mean and what to do about them. This checklist can support this process. Harvest/Spread Results Ongoing attention to performance on key targets beyond ‘focused QI projects’ is generally warranted e.g. because performance may backslide for various reasons. In addition, there is a growing list of targets on which improvement is imperative. It is therefore important to ‘harvest’ learning, strategies and tools from each project that can be applied in an ongoing way to the target, and spread to other targets. The CDS/QI Worksheet’s structure can facilitate such cross fertilization among QI targets.   Read More... As the scheduled initiative concludes, review the QI project with stakeholders to better understand what worked well, what could have been done better, and what useful tools were created.   Apply this learning and these results to strengthen ongoing ‘maintenance’ efforts on the current target and other target-focused QI initiatives.   Transition target-related QI efforts from ‘project-focused’ to ‘this is how we do business.’ Build in ability to detect the need for, and implement, tweaks to target-related processes when required because of changes to people/processes/technology.   Incorporate proactively the insights and results from each QI project into subsequent QI initiatives. Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets. For example, learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles, as well as health IT configurations with this latter triggering feedback to developers about broadly needed enhancements.   Contact the HITEQ Center if you are interested in sharing results further with your peers, and opportunities for health IT/QI peer learning.   Acknowledgements Origins and Ongoing Refinement of this Guide: The content in this resource is drawn from and builds on widely used CDS/QI tools and strategies that have evolved over the past decade. The HITEQ Center plans to continue refining this Guide based on input from users like you, so please consider sharing your feedback through the comment form. Read More... The content in this Guide is an adapted and expanded version of care process improvement guidance posted here on healthit.gov. That original material was developed by Jerome Osheroff, MD, TMIT Consulting, LLC in collaboration with ONC and Deloitte, and this version on HITEQ was also developed by Osheroff/TMIT in collaboration with JSI and others.   Guide Reviewers Individuals below each provided helpful feedback on an earlier draft of this guide; those marked with * provided particularly detailed feedback that led to substantial enhancements: Sheila Allen, MPH; Chief Compliance and Quality Officer, HealthNet, Inc. *Daren Anderson, MD; Director of the Weitzman Institute and VP/Chief Quality Officer of Community Health Center, Inc Sasha East, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital Renu George, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital *Meg Meador, MPH, C-PHI;  NACHC Director of Clinical Integration and Education *Jillian Maccini, MBA; Consultant, JSI Laura Methvin, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital Alan Mitchell; Program Director, Performance Improvement, Primary Care Development Corporation PCDC * Nivedita Mohanty, MD; Director of Evidence-based Practice, Alliance of Chicago Rick Reifenberg MD, FAAP, FACP, Associate Medical Director, HealthNet Inc.   Refinements to material on this page to enhance its use and usefulness are planned based on user feedback HITEQinfo@jsi.com.   Recommended citation for this Guide: Osheroff, Jerome A. "Improving Care Processes and Outcomes in Health Centers. HRSA Health Information Technology, Evaluation and Quality Center. JSI. 9 Sept. 2016. Web. 21 Nov. 2016 More Details...

Successful Practices in Accountable Care: Arizona Alliance For Community Health Centers: Oral Health for Whole Person Care (2020). Resource Type: Publication. Description: This document provides a brief overview of one state’s effort to recognize the value of integrated oral health care services in the primary care setting. It examines critical challenges, opportunities to overcome those challenges, and outcomes that others considering service integration should consider in their efforts to improve health outcomes with adequate payment state-wide. More Details...

Oral Health Value-Based Care: The Federally Qualified Health Center (FQHC) Story (2020). Resource Type: Publication. Description: NACHC collaborated with the DentaQuest Partnership for Oral Health Advancement to produce this white paper examining the role of FQHCs as facilitators of oral health value-based care. It also outlines various ways that FQHCs are positioned to respond effectively to the COVID-19 epidemic. More Details...

ACO Academy 2020 (2020). Resource Type: Archived Webinar. Description: As health centers continue to transition to value-based care and population health, more and more payer contracts include some form of risk (or financial burden for the services provided versus the amount of reimbursement expected in return). NACHC’s Accountable Care Academy is a 4-part webinar series focused on the fundamental considerations for risk-based contracts and how to prepare health centers for participation in arrangements with risk. More Details...

Value-Based Care: A Primer for Outreach and Enabling Services Staff (2020). Resource Type: Publication. Description: This publication outlines community health center traditional payment models and introduces value-based care and incentive payments to community health centers. It examines different incentive-based payment models and compares them to the current fee-for-service model community health centers have traditionally relied upon. More Details...

Making the Value Connection Whitepaper (2020). Resource Type: Publication. Description: Through the generous support of Cedars-Sinai, Capital Link and IHQC designed and piloted the Making the Value Connection (MVC) Program, a learning collaborative that creates resources to support community clinics in incorporating a comprehensive definition of value into their strategic priorities. 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...

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...

Medicare FQHC Updates: Calendar Year 2020 (2020). Resource Type: Publication. Description: Every year the Centers for Medicare and Medicaid Services issues an annual rule, the Physician Fee Schedule Final Rule, which provides details on new policies for Medicare providers. This update provides a summary of the latest changes, including any specific provisions in the CY2020 Physician Fee Schedule directly impacting FQHCs. More Details...

1332 Waivers and Health Centers: Update to Emerging Issues Brief 12 (2020). Resource Type: Publication. Description: This factsheet provides an update to 1332 Waivers and Health Centers: Emerging Issues #12, published in June of 2016. Section 1332 of the Patient Protection and Affordable Care Act allows states to waive certain provisions of the ACA in order to implement alternative approaches to coverage options. There have been a number of developments in this field; this update will reiterate topics that remain unchanged and highlight current waiver policy. More Details...

Successful Practices in Accountable Care: Model for Value Based Care and Contracting: Michigan Primary Care Association, Michigan Quality Improvement Network, Michigan Community Health Network (2020). Resource Type: Publication. Description: This publication highlights efforts of the PCA and HCCN in Michigan to develop a Clinically Integrated Network. It demonstrates the importance of PCAs and HCCNs collaborating and working together, leveraging the strengths of each organization in a model for value based care and contracting. Included are challenges the organizations faced and lessons learned. 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...

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...

Managing Your Health Center's Cost of Care (2018). Resource Type: Archived Webinar. Description: This session focused on the factors that influence the cost of care, providing information from new resources – a Capital Link study examining four-year trends across a series of cost-focused ratios and an updated NACHC issue brief providing a methodology for calculating costs. More Details...

Facilitating Change: Working Together, Engaging Others and Motivating for Change (2020). Resource Type: Archived Webinar. Description: Health centers are undergoing tremendous changes: considering shifting to value-based payment models; continuing to implement and optimize technology; creating data-driven quality improvement programs; and developing and enhancing multi-disciplinary care teams. More Details...

Successful Practices in Accountable Care: Building Capacity to Support Accountable Care: Washington Association for Community Health (2019). Resource Type: Publication. Description: This publication highlights Washington Association for Community Health efforts in supporting health center capacity around accountable care. It explores change areas within three domains of NACHC’s Value Transformation Framework (Infrastructure, Care Delivery, People) to provide concrete examples of successful capacity-building strategies. Readers will also gain insight into what it takes to support health center transformation from volume to value. 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...

Payment Innovation and Health Center Dental Programs: Case Studies from Three States (2018). Resource Type: Publication. Description: As dental care reimbursement follows the trends of healthcare overall towards value-based payment reimbursement, lessons from pioneers in dental payment innovation will inform effective health center strategies that will both strengthen the dental safety network and improve the oral health of the communities they serve. This document outlines interviews from organizations in three states on how health center dental programs are adapting clinical care systems under payment innovation incentives. More Details...

Office Hour: Quality Management for Clinical Leaders (2019). Resource Type: Archived Webinar. Description: In this Office Hour, Cheryl Modica, Director of NACHC's Quality Center, presents evidence-based and promising practices, including NACHC's Value Transformation Framework tool, to guide and accelerate your health center's transformation and improvement in achieving value-based care. The aim of this Office Hour is to increase a Clinical Leader's ability to actively participate and engage other clinical team members in effectively executing health center Quality Management activities, use bench-marking to actively identify clinical improvement opportunities, and support health center accreditation and Patient Centered Medical Home (PCMH) recognition. 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...

HITEQ Highlights: Developing Community Health Centers Along the Continuum of Pay for Performance (2019). Resource Type: Archived Webinar. Description: This HITEQ Highlights webinar described the continuum of value-based contracting, and suggested steps for health centers to move up the continuum. It also outlined basic elements of infrastructure to perform well in a value-based environment. Presenters from Yakima Valley Farm Workers Clinic presented their experience. More Details...

5 W’s of Business Intelligence (2019). Resource Type: Archived Webinar. Description: How do you know if your health center is ready to participate in a clinically integrated network? Health centers first need to be to assess their strategy, goals, staff, tools, and operational capacity needed for success in a value-based care environment. Next, the health center must identify an approach to value based care that clearly identifies who and how the work will be accomplished along with appropriate business tools to operationalize and measure impact and patient outcomes of those efforts. 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...

Advancing Health Center Value By Strengthening PCA & HCCN Capacity (2018). Resource Type: Publication. Description: This infographic provides an overview of available learning opportunities to support PCAs and HCCNs as they engage health centers in value-based strategies. 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...

What MACRA Means for Health Centers: Payment reform and health center impact (2016). Resource Type: Publication. Description: This HITEQ brief outlines Medicare Access and CHIP Reauthorization Act (MACRA) MACRA, what it signals for payment reform, and when it impacts health centers. Medicare Access and CHIP Reauthorization Act (MACRA) establishes the Quality Payment Program through the Merit Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Although most health centers are not affected by MACRA, they need to understand its components since MACRA reflects national trends to shift payment from volume- to value-based. This resource identifies several strategies health centers can take to respond to these shifting dynamics, even if MACRA requirements do not directly affect them for now. More Details...

Successful Practices in Accountable Care: Understanding Risk (2017). Resource Type: Publication. Description: This provides health centers with some tools and expertise necessary to analyze and prepare for risk-based contracting More Details...

Successful Practices in Accountable Care: Provider Health Link, LLC (2017). Resource Type: Publication. Description: This paper provides health centers with some of the benefits of an independent practices association and keys to successful participation in one. More Details...

Successful Practices in Accountable Care: Piedmont Health (2017). Resource Type: Publication. Description: This paper describes Piedmont Health's experience developing and implementing the PACE programs has prepared them to take on additional elements of accountable care. More Details...

Successful Practices in Accountable Care: Mountain Family Health Centers (2017). Resource Type: Publication. Description: This document outlines Mountain Family Health Centers' path to accountable care, focusing on their pursuit of value-based model of 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...

Successful Practices in Accountable Care: Carolina Medical Home Network (2017). Resource Type: Publication. Description: This paper provides practices implemented by the Carolina Medical Home Network to use medicare shared savings program to help health centers in their network adopt value based care. More Details...

Promising Practices Report: Community Outreach and Education Efforts of the Metta Health Center Program Within the Lowell Community Health Center (2017). Resource Type: Publication. Description: This report describes the development of a culturally tailored outreach and health education program through the use of radio and public access TV programming by the Metta Health Center Program in Lowell, MA. The health center has been recognized by the Office of Minority health as an exemplar provider of culturally competent care in meeting and exceeding all the standards set forth in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. More Details...

Preparing for Value-Based Care: A Guide for Health Centers (2018). Resource Type: Publication. Description: This publication serves as a primer on value-based care for community health centers, specifically as a means of treating chronic diseases. More Details...

Outreach to Residents of Public Housing (n.a.). Resource Type: Toolkit. Description: No annotation provided by the authoring organization. More Details...

Outreach Reference Manual: The Role of Outreach in Care Coordination Chapter (2015). Resource Type: Publication. Description: HOP’s Outreach Reference Manual chapters provide direction for how to most effectively use outreach to increase access to and utilization of comprehensive primary health care services across many underserved communities. This chapter makes the case for integrating outreach workers into care coordination teams and shares examples of how health centers can accomplish this. More Details...

Outreach Reference Manual: Program Planning and Evaluation Chapter (2015). Resource Type: Publication. Description: HOP’s Outreach Reference Manual chapters provide direction for how to most effectively use outreach to increase access to and utilization of comprehensive primary health care services across many underserved communities. This chapter guides readers through participatory planning methodologies and the development of three key frameworks: 1) a logic model that articulates what the program’s impact will be, 2) a work plan that outlines how the program will achieve that impact, and 3) an evaluation plan that outlines how the program will evaluate if it was successful. More Details...

Outreach Reference Manual: Clinical Outreach Chapter (2015). Resource Type: Publication. Description: HOP’s Outreach Reference Manual chapters provide direction for how to most effectively use outreach to increase access to and utilization of comprehensive primary health care services across many underserved communities. Clinical outreach is defined as the coordination and provision of clinical services in an outreach setting. It is an approach to meet individuals and communities where they are and to extend care in settings that best fit their needs and the context of their lives. The purpose of this chapter is to support health centers by providing a practical framework and guidance on undertaking clinical outreach efforts. It explores the different facets of clinical outreach and how it can be planned and implemented. More Details...

Outreach and Value-Based Care (2017). Resource Type: Publication. Description: HOP’s new resource Outreach & Value-Based Care: Impacting Health Care Delivery and Cost through Integrated Community Health Outreach Programs, describes how health centers can use their outreach teams to enhance value under service delivery models such as Patient Centered Medical Homes (PCMH) and Accountable Care Organizations. It offers examples of how outreach programs can enhance revenues from alternative payment models such as shared savings, pay-for-performance, and PCMH supplemental payments. The resource is a complement to HOP’s Outreach Business Value Toolkit. More Details...

Needs Assessment in Action Profiles (2016). Resource Type: Publication. Description: A community health needs assessment is a major undertaking for any health center. The Needs Assessment in Action Profiles: Innovative Approaches to Identifying the Needs of Underserved Communities is a resource for health centers to learn about effective strategies utilized by their peers. This resource offers examples of three innovative approaches that have been successfully implemented by health centers across the country. Each profile includes information on the population assessed, data collection methods, how findings were shared and applied, and lessons learned. Health centers can use this resource to apply proven strategies to the planning and implementation of their own needs assessment. More Details...

Introduction to Value-Based Payment for Health Centers: What is Value-Based Payment and why are Health Centers Considering Payment Reform? (2016). Resource Type: Publication. Description: This HITEQ brief introduces value-based payment and role of health centers as payment models shift. The brief answers key questions about health centers’ engagement in value-based payment, including health-center specific Alternative Payment Methodology (APM), reasons to engage in payment reform, the shifts in primary care payment going forward, and the transition to value-based payment. Value-based payment is a systematic method of paying for care that rewards the cost-effective improvement of the health and well-being of a population.  Payment reform is changing current volume-based payment system to alternative payment models (APMs) that link payment to outcomes and align financial incentives with providing value. By engaging in value-based payment models, health centers can lay the foundation for financial sustainability, high quality care, and engaged staff. This resource outlines value based payment and payment reform specifically tailored to the health center environment. More Details...

Innovative Outreach Practice Reports (2012). Resource Type: Publication. Description: HOP's Innovative Outreach Practices are a platform for organizations to showcase their outreach efforts, share their ideas and best practices, as well as mentor other organizations that seek both the inspiration and practical tools required to implement strategies, programs, and activities that have proven effective in the field. 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...

HITEQ Health App Decision Tree: A tool developed In collaboration with the Children's Health Fund to help choose appropriate Health Apps (2017). Resource Type: Publication. Description: There are thousands of consumer health applications health apps, which run on smartphones, watches, tablets, and other mobile devices. These Health Apps are available for download for general consumers, patients, and healthcare professionals. Currently, there is no governmental agency that provides certification or guidance on health apps, although there are several projects from organizations such as HL7, the FDA, ONC, and OCR that are working to provide guidance. User discrepancy in terms of the validity and safety of the health apps they choose to use are primarily based on ratings or recommendations. This guide seeks to provide a health app decision tree that can assist medical professionals and consumers in making wise choices when using health apps. There are thousands of consumer health applications health apps, which run on smartphones, watches, tablets, and other mobile devices. These health apps are available for download for general consumers, patients, and healthcare professionals. Currently, there is no governmental agency that provides certification or guidance on health apps, although there are several projects from organizations such as HL7, the FDA, ONC, and OCR that are working to provide guidance. User discrepancy in terms of the validity and safety of the health apps they choose to use are primarily based on ratings or recommendations. This guide seeks to provide a health app decision tree that can assist medical professionals and consumers in making wise choices when using health apps. The Children's Health Fund was made aware of a use case in which a health app that was targeted for use by adults was used for a child and consequently caused a detrimental health issue. Currently there are no certifying bodies for consumer-oriented health apps and consequently many doctors must navigate this domain themselves. This guide seeks to provide a health app decision tree that can assist medical professionals and consumers in making wise choices when using health apps. Download the decision tree below. More Details...

Highlighting the Role of Enabling Services at Community Health Centers: Collecting Data to Support Service Expansion and Enhanced Funding: The Enabling Services Accountability Project (2010). Resource Type: Publication. Description: This issue brief, written collaboratively between AAPCHO and the National Association of Community Health Centers (NACHC), describes the importance of enabling services (ES), such as interpretation and eligibility assistance, and how better quantifying the provision of these services can demonstrate their value to private and public payers. More Details...

Enabling Services: Gateways to Better Care (2016). Resource Type: Publication. Description: This fact sheet was developed by AAPCHO and the National Association for Community Health Centers (NACHC). It provides an overview of the leading role health centers play in providing enabling services, or non-clinical services that improve access to care, and the important and positive impacts these services can have on health outcomes, costs, access and patient satisfaction. More Details...

Enabling Services Data Collection Implementation Packet: Enabling Services Accountability Project (2017). Resource Type: Toolkit. Description: This toolkit includes tools and recommendations for how health centers can better capture data on enabling services (ES). This will help health centers provide a better understanding of the role of ES in health care access, utilization and outcomes for Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs), and useful information to appropriately address these needs. 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. More Details...

Current Population Health Management in Health Centers: The Case for Implementing Population Health Management and Addressing the Social Determinants of Health (2016). Resource Type: Publication. Description: This is a 27-slide module on population health management in the Federally Qualified Health Centers (FQHCs). The module provides several examples of current initiatives that support PHM and SDM as well as the use of these concept in supporting health equity in navigating the Affordable Care Act (ACA). This is a 27-slide module on population health management in the Federally Qualified Health Centers (FQHCs). The module provides several examples of current initiatives that support population health management and social determinants of health as well as the use of these concept in supporting health equity in navigating the Affordable Care Act (ACA). The module also serves to specifically outline the rationale of PHM in areas of cost efficiency, quality improvement and patient care including value-based reimbursement and risk contracts, targeting care and resources to improve outcomes, and patient engagement and care management.   More Details...

Cost Per Visit: Measuring Health Center Performance (2018). Resource Type: Publication. Description: Developed by Capital Link and the National Association of Community Health Centers (NACHC) as an update to NACHC’s original 2003 publication,Cost Per Visit – Measuring Health Center Performance, reviews in detail the process and methodology for calculating the component costs of care with a focus on cost per visit across all service lines — medical, dental, mental health (including substance abuse), and vision services. It also examines methods for reducing health center costs through population health management, global payment methodologies, and tying reimbursements to outcomes. More Details...

Community Health Needs Assessment Toolkit (2015). Resource Type: Toolkit. Description: The toolkit, "Community Health Needs Assessment: A Comprehensive Guide to Understanding and Responding to the Needs of Your Community,” provides a wealth of information, practical tools, and strategies to support organizations in their efforts to meet the health needs of underserved populations. The easy-to-use toolkit guides the user through the 5 key steps of the needs assessment process, and it is intended for health centers, Primary Care Associations, safety net providers, and local and state agencies. More Details...

Coding Social Determinants of Health (SDH) for Optimizing Value: An Infographic for Providers on the Benefits of Coding for SDH (2017). Resource Type: Publication. Description: The purpose of the infographic is to describe how SDH data would be used for a variety of goals that would have traction with the clinic staff audience who may likely need to modify workflows and behavior in order to collect such data.  The visual case could be used in presentations or hung on a provider break room wall. 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...

Centering 101: Transforming Care With Group Visits (2018). Resource Type: Archived Webinar. Description: As health centers continue to seek and identify innovative strategies to engage in value-based care, some have found great success in hosting and organizing group visits through a practice known as Centering. This evidence-based model includes elements of health education and community building, led by providers, with success in improving health outcomes. Traditional models focus on pregnancy and parenting, and new and emerging models help patients manage chronic conditions such as diabetes. Join staff from NACHC, the Centering Healthcare Institute, the Texas Association of Community Health Centers, and CCI Health & Wellness in Silver Spring, MD as they discuss the basics of the Centering model. Learn how Centering can contribute to improved health outcomes and the value of the program as health centers continue to be key players in payment and delivery reform. More Details...

Asian Americans, Native Hawaiians, and Pacific Islander (AA&NHPI)-Serving Health Centers and Medicaid (2017). Resource Type: Publication. Description: This fact sheet outlines the impact of potential cuts to Medicaid on Asian American, Native Hawaiian and Pacific Islanders (AA&NHPIs) and health centers. More Details...

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This project 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 $6,625,000 with 0 percentage 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.