The impact of social factors such as food insecurity, poverty, and transportation on health status is undeniable. Extensive research estimates that up to 20 percent of health outcomes are a result of social and environmental risk factors. To address patients’ unmet social needs before an acute care episode, population health managers increasingly extend care model interventions into the community.
For community-based interventions to be sustainable and effective, they must be as purpose-driven as clinical interventions, well-supported by data and continuously assessed for efficacy. Community engagement starts with leveraging data to identify how to best allocate limited resources. From there, providers can prioritize activities that align to the greatest community needs, community groups, and core population health goals.
This toolkit outlines four steps for focusing on the highest return community health needs: Define core measures, prioritize key activities, create formal partnership compacts, and evaluate performance of community-based interventions. Each step is supported by sample resources including surveys, prioritization tools, and metric pick lists.
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Integrating Psychosocial Risk Factors into Ongoing Care