Resource Search Results

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...

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

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

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...

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

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

HUD Policy Brief for Health Centers - Data Matching with Housing Community: Understanding the Role and Impact of Housing Policy for Health Centers (Data Matching) (2019). Resource Type: Publication. Description: Health centers and housing providers are serving the same clients, and HUD policies foster opportunities for partners to effectively share data target and improve Health Outcomes. 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...

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

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...

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...

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...

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 & Data Measures: A Quick Guide for Health Center & Housing Partnerships: 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...

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

Data for Population Health Management: Measuring Population Health & Emerging Directions in Population Health (2016). Resource Type: Publication. Description: This is an 18-slide module describes the role and importance of data to population health management. This is an 18-slide module describes the role and importance of data to population health management. This includes the various sources for data that inform population health management, an introduction to population health analytics; and recommended frameworks for collecting data and measuring impacts and outcomes of population health. The module concludes with a brief discussion of areas of future research and development in population health management. More Details...

Who Are Frequent Users in Health and Housing Systems?: A Closer Look at Definitions Used by Communities to Identify the People Cycling Through the Crisis Care Systems (2015). Resource Type: Archived Webinar. Description: Are frequent users costing your crisis care systems and not producing positive houtcomes? Is your community looking at how to identify the frequent users across multiple crisis care systems in an effort to deliver more effective services and save resources? This webinar highlights how various communities develop the criteria to define 'frequent user' across the systems of care and how to match data to identify those individuals. More Details...

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