As part of the Foundation’s signature Population Health initiative, RCHN CHF collaborated with project grantees to co-design a learning collaborative and to share information among grantees and their partners. Learning sessions focused on approaches to deepen and strengthen health center operational and clinical capacity, develop partnerships, and enhance the potential for sustainability. Through regular learning community interactions, participants shared their experience in implementing a diverse set of interventions and learned from each other and expert faculty. The resources and tools identified throughout the learning collaborative may be useful to other health center organizations in their journey to improve population health and are presented here in the spirit of collaboration and expanding general knowledge. The resources are grouped to reflect major categories  – Environmental Drivers, Steps to Population Health, and Process Outcomes –  that are relevant  for all  health center population health management work regardless of the target population identified for interventions.
  • Social Determinants of Health
  • Patient Identification, Assessment, Stratification
  • Person-Centered Care Design and Processes
  • Partnerships & Multi-Stakeholder Collaborations/Collaboratives
  • Patient Engagement
  • Quality Improvement & Impact Evaluation
  • Policy and Payment Environment
  • Health Information Technology and Data Analysis
  • Community-Level Population Health Management
This page will be updated periodically as new resources are added.


Social Determinants of Health (SDoH)
In describing Social Determinants of Health, the World Health Organization writes: “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”  Improving population health requires that requires that the social, cultural, and economic forces that impact health status be assessed and addressed through community-level action. 

  • Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)
  • Social Determinants of Health Needs Assessment Survey and Staff Assessment (Colorado Community Health Network. 2015)
  • Policy Reports: An Overview of Food Insecurity Coding in Health Care Settings: Existing and Emerging Opportunities (Hunger Vital Sign National Community of Practice. January 2018)

Partnerships & Multi-Stakeholder Collaboratives/Coalitions
Effective population health management requires local and regional partnerships that support coordination or integration of services, information sharing, leveraging resources, and raising awareness and participation at the community level.

  • Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities – Action Guide 2.0 (National Quality Forum. June 2015)
  • Working Together, Moving Ahead: A Manual to Support Effective Community Health Coalitions (Shoshanna Sofaer, Dr.P.H. School of Public Affairs, Baruch College. 2001)
  • A Standard Framework for Levels of Integrated Healthcare: (SAMHSA-HRSA Center for Integrated Health Solutions. March 2013)
  • Integrated Practice Assessment Tool (IPAT) (Colorado Access, ValueOptions, Axis Health System. 2014)
Local, state and federal health laws and regulations may help support population health by assuring access to health care and needed services, strengthening the economic health of communities, and encouraging collaboration among different health related organizations, and supporting expanded roles for health care professionals.

  • Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Brief Series (2008-present)
  • The Economic and Employment Consequences of Repealing Federal Health Reform: A Fifty State Analysis. (Milken Institute School of Public Health, the George Washington University. January 2017)
  • Repealing Federal Health Reform: Economic and Employment Consequences for States (The Commonwealth Fund. January 2017)
  • Related Interactive Map: The Impact of the American Health Care Act on Employment (The Commonwealth Fund. 2017)

The ongoing operation and sustainability of population health strategies rests upon both strong business models and appropriate reimbursement. Community health centers represent one of the principal sources for care for the nation’s Medicaid population, and an understanding of the enduring and interdependent relationship with Medicaid is essential, as is appreciation of the opportunities for transformation through payment reform.


Patient Identification, Assessment, Stratification
Identifying the target population, assessing need, and stratifying the community based on risk are essential to developing effective population health improvement strategies.  This effort requires both solid data, and the use of patient- and community-focused decision support tools.  
  • Screening, Brief Interventions, and Referral to Treatment (SBIRT)
  • The Patient Health Questionnaire (PHQ-9)
  • Short Form Health Survey SF-20

Related resources: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) and Social Determinants of Health Needs Assessment Survey and Staff Assessment (Colorado Community Health Network. 2015) in Social Determinants of Health (SDoH)

Patient Engagement
Successful population health management, at the patient or the community levels, requires that individuals have the capacity to understand and participate in improving their health and preserving their wellness.

  • Working With Patients and Families as Advisors (Agency for Healthcare Research and Quality. June 2013)
  • Quitting Smoking is Hard, But You Can Do It! (Charles B. Wang Community Health Center. 2016)

Health Information Technology and Data Analytics
To support informed population health-oriented decision making at the practice and organizational levels, timely and accurate data, actionable information and a capacity to analyze and share it are essential.  


Person-Centered Care Design and Processes
In order to improve population health outcomes, the way care is delivered and the experience it creates for patients and families must be assessed and often transformed to achieve improvement.

  • Organized, Evidence-Based Care: Behavioral Health Integration – Implementation Guide Supplement (Safety Net Medical Home Initiative. October 2014)
  • New Models of Primary Care Workforce and Financing (Agency for Healthcare Research and Quality [AHRQ]. October 2016)
  • Integration of collaborative medication therapy management in a safety net patient-centered medical home (Journal of the American Pharmacists Association. March/April 2011)
  • Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis (The Commonwealth Fund. October 2015)
  • Advancing Quality Family Planning Practices: A Guide for Health Centers (The National Association of Community Health Centers. April 2017)
  • Asthma Community Network – Communities in Action
  • Effectiveness of Evidence-Based Asthma Interventions (Pediatrics. May 2017)

Related resource: Core Competencies for Integrated Behavioral Health and Primary Care (SAMHSA-HRSA Center for Integrated Health Solutions, January 2014) in Quality Improvement & Impact Evaluation.

Quality Improvement & Impact Evaluation
Population health improvement strategies are both essential to practice transformation, and driven by the need to transform care and improve quality while strengthening capacity for sustainability. Measurement and evaluation approaches require a baseline assessment and metrics that are well aligned with the interventions, and based on well-documented standards.
  • The Core Quality Measures Collaborative
  • The Institute for Healthcare Improvement (IHI) Improvement Capability Self-Assessment Tool (2010)
  • Core Competencies for Integrated Behavioral Health and Primary Care (SAMHSA-HRSA Center for Integrated Health Solutions, January 2014)
Community-Level Population Health Management
Population health management encompasses initiatives focused on improving outcomes for a defined population in a community or geographic region, rather than those strictly limited to health center or facility-specific patients and families. These resources describe such community-focused, equity-oriented efforts and provide tools, ideas and strategies that may be adapted to address local conditions.
  • New York Community Health Centers’ Population Health Activities: Findings from a Statewide Assessment (Journal of Health Care for the Poor and Underserved. May 2017) (Abstract Only)
  • Pathways Community HUB Manual: A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes (Agency for Healthcare Research and Quality. January 2016)
  • Smoking Cessation – Integrating Tobacco-Dependency Treatment Interventions with Primary Care (Charles B. Wang Community Health Center. August 2016)