Resource Overview

Population Health Management (PHM) is an evolving concept encompassing a suite of emerging technologies to aggregate, analyze and use data to improve clinical and financial outcomes.  PHM tools enable health centers to identify, monitor and target care to patients within a population. Resources in this section provide a conceptual foundation to help health center staff deepen their understanding of PHM and how the social determinants of health can be used to improve outcomes.

PHM and SDH Concepts and Overview Resources
Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources

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

Using standardized social determinant of health data can improve overall care.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.

Assess Need and Respond to Need

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:

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.

Example Process for Using SDoH to identify and respond to need.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!

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Intended AudienceHealth Center Leadership, Population Health Management Staff, Clinicians

Documents to download


This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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