Resource Search Results

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

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

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

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

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

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

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

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

SDOH Academy Resources (2019). Resource Type: E-Learning. Description: The Social Determinants of Health (SDOH) Academy is a HRSA-funded virtual training series designed to help staff from health centers, health center controlled networks, and primary care associations develop, implement, and sustain SDOH interventions in their clinics and communities. The power of The SDOH Academy is that it does not focus on a single intervention. Instead, multiple HRSA-funded national training and technical assistance partners work together to offer a coordinated curriculum on multiple community-based SDOH interventions. More Details...

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

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

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

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

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

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

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

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

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...

Population Specific Approaches to SDOH: Elderly, LGBT, Migrant Workers and Public Housing Residents (2018). Resource Type: Archived Webinar. Description: Individuals within certain special and vulnerable populations experience health inequalities and therefore are at a higher risk of late detection, inadequate management and treatment of diabetes. Improved access to certain non-clinical enabling services and a comprehensive social history is essential to understanding the needs of these often overlooked individuals, and developing interventions that address those needs. More Details...

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