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Displaying records 301 through 320 of 423 found.

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...

Collecting Data On Asian Americans, Native Hawaiians, And Pacific Islanders For Community Health Center Needs Assessments: A Learning Series - Part 1: Social Determinants of Health of Emerging Asian Americans, Native Hawaiians, and Pacific Islander (AA&NHPI) Populations by States (2017). Resource Type: Archived Webinar. Description: This webinar provides a data portrait of the fastest growing AA&NHPI populations by state with profiles of their social determinants of health characteristics. The five states are Arizona, Arkansas, Nevada, North Carolina, and North Dakota. The seven SDOH characteristics mentioned are educational attainment, foreign born, language spoken at home and ability to speak English, employment status, health insurance coverage, poverty level, and household characteristics. Collecting and having disaggregated data is important to better understand the unique barriers faced by AA&NHPIs since they represent more than 50 ethnic groups and over 100 languages. Health centers can use this data to develop more culturally and linguistically appropriate programs to better serve these communities. More Details...

Promising Practices for Health Centers: 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...

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 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...

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...

Growing Our Own: Cultivating the Next Generation of Primary Care Physicians in Community Health Centers (2017). Resource Type: Publication. Description: It is critical to advance policies and programs that help community health centers (CHCs) become Educational Health Centers (EHCs)2 and “grow their own” primary care training opportunities. This paper explores several pathways for promoting CHCs as teaching environments - enhanced partnerships between Academic Medical Centers (AMCs) and CHCs (with either the AMC or the CHC as the sponsoring institution3), and CHCs participating in HRSA Teaching Health Center (THC) funding opportunities (with sponsorship either by the CHC alone or by a consortium body) - and posits a spectrum of options and costs associated with each of these pathways to train medical residents. 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...

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...

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...

Demystifying Predictive Analytics: Factsheet on Predictive Analytics for Health Centers (2017). Resource Type: Publication. Description: Using predictive analytics in health care is an emerging field, especially for health centers. This tool will provide a brief explanation of the purpose of predictive analytics, the ingredients necessary to apply these methods, and ways that health centers are using this approach to improve results. The objective of this resource is to help health center leadership and staff understand how and when predictive analytics can help them, and to think about how predictive analytics might fit into their data-driven QI program. This one-page brief outlines the basics of this complex topic. We define predictive analytics and describe how health centers are adopting this innovation. Sources and uses of data for making predictions are discussed, and specific applications of predictive analytics are described.  Specific health center examples are offered to illustrate the potential of predictive analytics for health centers. 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...

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...

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...

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...

Emerging Issues in Payment Reform: Engagement at the State Level and Opportunities to Address the Social Determinants of Health (2017). Resource Type: Archived Webinar. Description: This webinar focuses on the national and state payment reform landscapes and its administrative changes to explain how they are used in different states and why. It also details how some health centers document social determinants of health (SDOH), and how this could influence delivery system reform. Lastly, It highlights different strategies and tools health centers could use to connect with key players on the state levels. 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...

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...

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...

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...

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.