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The ongoing need for health equity continues to intensify as organizations attempt to understand systems, policies and activities to address social needs and to integrate care across settings. Aligning quality, care management programs and community wraparound services requires an evidence-based process that considers organizational budgets, workflows and clinical and data reporting systems, and applies an effective care team structure. PCMH offers a practical framework for implementing steps to achieve community care objectives including collecting and analyzing data and executing interventions to improve care gaps and social barriers.
To align program performance and reporting, payers and providers must understand the social structures and economic systems that lead to inequities in health access and outcomes in their populations. Identifying and synthesizing performance improvement activities with PCMH criteria and quality programs such as Medicare and Medicaid programs is one way to do this.
How can the PCMH structure help organizations identify patient population characteristics that create disparities? How can organizations identify suitable sources of data to evaluate population needs and intervention impact?
PCMH Recognition program core and elective criteria encourage collection, reporting of quality measures and activities that emphasize SDOH.
Patient Access and Continuity (AC)
Accessing information about the population served enables health care and community stakeholders to determine health disparities and opportunities to improve equitable access.
- Patient Access to the Health Center
Knowing and Managing Your Patients (KM)
Understanding barriers to health, utilization and positive outcomes is critical for determining population needs. Health care stakeholders can collect information through embedded screening questions in EHRs or can use referral management tools to standardize connectivity and clinical workflows. Integrating social and clinical services gives community health workers the ability to collect data that captures health disparities—such as behaviors affecting health, and communication and language needs—as well as a population’s socioeconomic characteristics.
- Collecting Patient Information
- Patient Diversity
- Connecting with Community Resources
Care Management and Support (CM)
Once social barriers are identified, a population can benefit from integrated care management that identifies high-risk individuals and closes health disparities and care gaps—for example, engaging patients in vaccination programs based on education level or providing diabetes education to patients of Hispanic/Latino ethnicity based on clinical quality data.
- Identifying Care Managed Patients
Performance Measurement and Quality Improvement (QI)
Assessing health disparities while evaluating quality performance data segmented by vulnerable populations can help identify appropriate levels and methods of patient engagement to encourage adherence to clinical protocols, such as medication and well visits, and manage resource utilization.
- Measuring Performance
- Setting Goals and Acting to Improve
Managing Patients, Closing Gaps, Improving Performance
Aligning existing quality improvement, care management and resources with the PCMH structure is an efficient approach to implementing community care that considers SDOH. Stratified data can help organizations set goals and actions based on quality performance:
- Use screening data to identify and prevent health gaps, such as preventable use of ED and hospital services or missed well-visit appointment rates.
- Customize patient outreach and education, such as using a population’s preferred language or virtual or in-person engagement.
- Community or external resource needs such as transportation or translation services.
- Prioritize services based on health and social risks reported in quality measures.
- Recruit health care and social workers to engage in activities that align with similar demographics.
- Promote community partnerships as a trusted source of education and communication.
- Implement HIE or EHR tools to facilitate standardized workflows, care reminders and alerts, care team communication, and prioritization and
performance reporting data.
1. How does your organization align measures and strategies to close gaps in care and health inequities?
2. What submission methods or formats has your organization identified as having the most impact on workflows and performance?
3. Do quality measures and SDOH PCMH criteria overlap? How has your organization aligned activities?
4. What clinical or operational challenges should stakeholders consider when aligning PCMH with quality programs and activities (e.g., utilizing EHR and HIE tools)?
Vanessa Guzman,CEO,SmartRise Health
Vanessa Guzman is an expert in population health strategies, including patient and physician engagement strategies, clinical reporting, health IT and quality management models, and CEO at SmartRise Health. With almost 15 years of industry experience, she works closely with health systems, Accountable Care Organizations (ACOs), technology, and SDOH partners to collaborate in implementing data-driven tools, clinical infrastructures, and community partnerships to promote wellness and improve patient health outcomes.
Vanessa served as the Associate Vice President at the Montefiore Health System, a top-performing ACO in the country, overseeing physician partnerships, population health and quality improvement, and health information technology.