Population Health Management

How Community Health Centers Support Transitions Out of Incarceration

February 12, 2024 - As the healthcare industry continues to eye better transitions of care for patients who are recently incarcerated, community health centers agree they are poised to fill the gap, according to a new assessment from The Commonwealth Fund. However, to make that happen, CHCs will need additional supports and resources to overcome current limitations,...


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VA Cuts Homelessness, SDOH by 55% with Housing First Model

by Sara Heath

The Veterans Health Administration (VHA) was able to reduce homelessness by 55 percent over a 13-year period, demonstrating the power of integrating social determinants of health interventions into the...

Top Technologies Supporting Social Determinants of Health Work

by Sara Heath

While most health system social determinants of health initiatives are fundamentally about uncovering and fulfilling social needs, those efforts would not be complete without the health IT necessary to support them. Indeed, programs that...

Top Patient Engagement Technologies for Population Health Management

by Sara Heath

Any good population health strategy needs good patient engagement, and as a part of that, good patient engagement technologies. Defined by the Centers for Disease Control & Prevention, population health is an “interdisciplinary,...

Which Social Determinants of Health Lead to Low Care Quality?

by Sara Heath

The different social determinants of health have different impacts on healthcare quality, utilization, and outcomes, with new Humana data showing that some SDOH are more closely related to poor care...

Patient Trust in Clinician, Public Health Expert Credibility an Uphill Battle

by Sara Heath

The healthcare industry has a big credibility and patient trust problem on its hands, with new data from Edelman showing that 34 percent of people think any average layperson could know just as much as...

How Community Health Workers Support Hearing Loss Intervention

by Sara Heath

Listen up: a new program out of the Johns Hopkins Cochlear Center for Hearing and Public Health shows that community health workers can effectively connect low-income seniors with hearing aids. The...

Accountable Health Communities Grant Cut Healthcare Utilization

by Sarai Rodriguez

By implementing a cross-sector community health program to address a communitywide social determinant of health, Reading Hospital, an Accountable Health Communities (AHC) model grantee, addressed food...

Access to Contraceptives Improves College Graduation Rates 12%

by Sara Heath

Access to contraceptives via the federal Title X Family Planning program increased the rate at which women graduated with a bachelor’s degree by between 6 and 12 percent, underscoring how...

Epic Sets Sights on Healthcare Consumerism with CRM Platform Launch

by Sara Heath

Think of a marketing campaign, but it’s rich with thousands of patient data points from the EHR to help tailor patient outreach and meet the moment on healthcare consumerism. That’s the pitch from Epic Systems with its newly...

Using Risk Stratification in Patient Engagement Strategies

by Sara Heath

As healthcare professionals continue to develop meaningful patient engagement strategies, they should consider using risk stratification to determine how and with which patients providers will...

Aligning Care Coordination Work Amid Healthcare Workforce Shortage

by Sara Heath

Healthcare organizations nationwide are staring down competing priorities to increase care coordination for complex patients while staving off provider burnout for a dwindling workforce. It can sometimes feel like those goals are mutually...

How Lyft Healthcare Changed Lanes to Social Determinants of Health Work

by Sara Heath

It was 2016, and the leadership at burgeoning rideshare company Lyft was alerted to several tripped fraud wires. What looked like fraudulent ride requests coming out of Utah for trips in New York turned out to be a medical transportation...

Considerations for Social Determinants of Health Screening Design

by Sara Heath

Increasingly, healthcare organizations are starting to design social determinants of health screening processes. Coming as a response to value-based care trends, social determinants of health screenings help clinicians and organization...

Understanding Environment, Climate as Social Determinants of Health

by Sara Heath

As the medical industry continues to understand how social determinants of health impact overall wellness, the topics of environment and climate change have come into view. SDOH specifically refer to the environments in which individuals...

Smoking Trumps Other Social Determinants of Health Impacting Mortality

by Sara Heath

Smoking was the leading social determinant of health affecting mortality and life expectancy, although income was another strong SDOH predictor, according to researchers from the Center for Population...

Community Health Centers Played Critical Role in COVID-19 Response

by Sarai Rodriguez

Since the start of the COVID-19 pandemic, community health centers have been on the frontlines delivering equitable care to historically underserved populations. An announcement from the National...

Data on Justice-Involved Populations Targets SDOH, Cuts Recidivism

by Sara Heath

Clocking in at around $150,000 in a single state annually, recidivism is a costly problem for the American taxpayer, and yet one of the most poignant examples of where concerted care coordination and...