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 Core Quality Measures Collaborative is an effort convened by The Centers for Medicare & Medicaid Services (CMS), in conjunction with collaborators representing insurers, purchasers, physician and other health care provider organizations and consumers, to develop consensus measures that could be harmonized across public and commercial payers.  Reviewing these measures will help health centers decide on the best metrics for their population health quality improvement efforts. The core quality measures include a measurement set with an emphasis on primary care: Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care. Seven additional measurement sets, some of which also include primary care related metrics, are: Cardiology; Gastroenterology; HIV and Hepatitis C; Medical Oncology; Obstetrics and Gynecology; Orthopedics; and Pediatrics.

CMS and America’s Health Plans (AHIP) released the consensus core set (V 1.0) for ACO and PCMH/ Primary Care Measures in February2016. Current measures sets are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html

The Institute for Healthcare Improvement (IHI) Improvement Capability Self-Assessment Tool (2010)
This tool, originally developed by IHI for hospitals participating in the Health Disparities Collaboratives (a national quality improvement initiative developed by the Bureau of Primary Health Care and the IHI, operational 1999-2006), assesses organizational capability in several domains that are associated with  overall outcomes-improvement success: 1) Leadership for Improvement; 2) Results; 3) Resources; 4) Workforce and Human Resources; 5) Data Infrastructure and Management; and 6) Improvement Knowledge and Competence.

Core Competencies for Integrated Behavioral Health and Primary Care (SAMHSA-HRSA Center for Integrated Health Solutions, January 2014)
This set of core competencies was created under the auspices of the Center for Integrated Health Solutions by the Annapolis Coalition of Behavioral Health Workforce and addresses integrated practice relevant to behavioral health and primary care providers. It is intended to serve as a resource of common competencies for provider organizations as they shape job descriptions, orientation programs, supervision, and performance reviews for staff delivering integrated care. It is also a resource for educators as they shape curricula and training programs on integrated care.


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)
The New York Prevention Agenda (NYPA) is the state’s plan to improve the health of populations across the state. The five NYPA priority areas include: 1) preventing chronic disease; 2) creating safe environments; 3) promoting health among women and children; 4) promoting mental health/preventing substance abuse; and 5) reducing HIV and sexually transmitted infections. The Community Health Care Association of NYS (CHCANYS) surveyed N.Y. community health centers (CHCs) about their activities across 16 focus areas corresponding to the NYPA priority areas. The study establishes a baseline of population health activities among CHCs in New York. The authors found that CHCs are engaged in population health activities across all NYPA priority areas and considered population health to be a top priority. Still, the authors conclude that dedicated funding to support evidence-based prevention and population health strategies are essential to achieve widespread expansion of CHC-driven population health activities.

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)
First developed by the Community Health Access Project, Pathways Community HUB (HUB) model is a community care coordination approach focused on reducing modifiable risk factors for high-risk individuals and populations. The HUB relies on community care coordinators (CCCs) – community health workers, nurses, social workers, and others – who reach out to at-risk individuals through home visits and community-based work. The publication provides a quick start reference guide and resource for public and private stakeholders engaged in improving the community care coordination system for identifying high-risk individuals; documenting their specific health, social, and behavioral health risk factors; and addressing those risks in a pay-for-performance approach.

St. Louis Integrated Health Network is a member-based organization of community health centers, hospitals, public health departments, medical schools, and other safety-net organizations that works to advance quality, accessible and affordable health care services for all residents of metropolitan St. Louis. Its Community Referral Coordinator program and Transitions of Care Task Force aim to streamline care transitions and help patients navigate across and between systems of care with a focus on primary and preventive care.

Smoking Cessation – Integrating Tobacco-Dependency Treatment Interventions with Primary Care (Charles B. Wang Community Health Center. August 2016) The Charles B. Wang CHC developed and implemented a multi-model population-based intervention to advance smoking cessation in an at-risk population. The initiative included community outreach, one-on-one counseling, nicotine replacement therapy and other approaches. Background, methods and strategy, and initial outcomes are depicted in this poster, presented at the NACHC Community Health Institute and Expo. 

Related resource: Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities— Action Guide 2.0 (National Quality Forum. June 2015) in Partnerships & multi-stakeholder collaboratives/coalitions.


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)
SBIRT is an evidence-based practice to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.  The SBIRT model is intended to respond to Institute of Medicine recommendations calling for community-based screening for health risk behaviors, including substance abuse, and consists of three main components focused on: screening and assessment by a healthcare professional using standardized tools; brief direct interventions; and appropriate referrals for additional treatment.

An overview of SBIRT is available via the SAMHSA- HRSA Center for Integrated Health Solutions http://www.integration.samhsa.gov/clinical-practice/SBIRT. Additional resources, reimbursement and financing information are available at: www.sbirttraining.com.

The Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire (PHQ-9) is a multi-purpose, self-administered questionnaire used for screening, diagnosing, monitoring, and measuring the severity of depression.  The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV (Diagnostic and Statistical Manual Fourth Edition).  (© 1999 Pfizer Inc.) 

Short Form Health Survey SF-20
The 20-Item Short Form Health Survey (SF-20) was developed for the Medical Outcomes Study (MOS), a multi-year study of patients with chronic conditions, to describe mental and physical health status of adults, and to measure the outcomes of health care service. The domains addressed are physical functioning, role functioning, social functioning, mental health, and current health perceptions.

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).


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.  

Natural Language Processing (NLP) and Auto-Indexing in Healthcare (RCHN CHF. July 2016)
A brief prepared by Dr. David Hartzband, RCHN CHF Director of Technology Research, on the use of auto-indexing and NLP in health care applications and their value to community health centers.

Understanding Data as an Asset – It’s a Necessity, Not a Luxury (Community Health Forum. Summer/Fall 2016)
Article by Dr. David Hartzband and Dr. Feygele Jacobs outlines the importance of data awareness and strong information management capacity in a rapidly transforming health system.

Deployment of Analytics into the Healthcare Safety Net: Lessons Learned (Online Journal of Public Health Informatics. 2016)
This article by Dr. David Hartzband and Dr. Feygele Jacobs summarizes lessons learned from a multi-site initiative to evaluate health center data accuracy, reliability and completeness, and offers recommendations aimed at helping health centers answer two strategic questions: 1) How good are your data? and 2) How good are your systems?


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)
The National Quality Strategy (NQS) prioritizes community efforts and interventions to improve social, economic, and environmental factors that impact health. Under contract with HHS, the National Quality Forum, using a multi-stakeholder, collaborative process, is developing a common framework that offers practical guidance for improving population health at the community level. The Action Guide handbook, intended for use by professionals of all disciplines and working at the local, regional, state, and national levels suggests ten elements important for building or refining initiatives to improve population health.

Working Together, Moving Ahead: A Manual to Support Effective Community Health Coalitions (Shoshanna Sofaer, Dr.P.H. School of Public Affairs, Baruch College. 2001)
This report was one of several products of a multiyear assessment and formal evaluation of statewide tobacco control coalitions funded by the Robert Wood Johnson Foundation through its SmokeLess States Initiative. The manual aims to provide insight about the nature and development of community coalitions, and related structures and processes, while providing a practical guidebook for those using coalitions in their work.

A Standard Framework for Levels of Integrated Healthcare: (SAMHSA-HRSA Center for Integrated Health Solutions. March 2013)
This issue brief reviews levels of integrated healthcare and proposes a functional standard framework for classifying sites according to these levels. The overarching framework has three main categories – coordinated, co-located, and integrated care –  and there are two levels of degree within each category. As depicted in the table, this framework is designed to help organizations implementing integration to evaluate their degree of integration across several levels and to determine what next steps they may want to take to enhance their integration initiatives.

Integrated Practice Assessment Tool (IPAT) (Colorado Access, ValueOptions, Axis Health System. 2014)
The IPAT assessment tool is based on the issue brief, A Standard Framework for Levels of Integrated Healthcare. In contrast to other tools, it utilizes a decision tree model through a series of yes/no questions cascades to determine the level of healthcare integration and situate practices on the continuum identified in the brief.


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) – A national, multi-year effort to help community health centers collect meaningful data on social determinants of health and respond to community needs.  Created as an open-source tool through a collaborative stakeholder-involved process, PRAPARE consists of a set of national core measures and optional measures aligned with national initiatives. Templates are available for electronic health record applications including EPIC, NEXT GEN, eClinicalWorks and GE Centricity. PRAPARE was developed by National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations (AAPCHO), and the Oregon Primary Care Association with funding support from the Kresge Foundation, Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation, and Blue Shield of California Foundation. PRAPARE resources are available at http://www.nachc.org/research-and-data/prapare/toolkit/.

Social Determinants of Health Needs Assessment Survey and Staff Assessment (Colorado Community Health Network. 2015)
These tools are part of a comprehensive guide, “Patient Engagement: A toolkit from the Colorado Community Health Network.” The needs assessment survey is intended to help organizations gauge and enhance the patient’s understanding and knowledge of the social determinants of health (SDoH) in the community in which they live and/or receive care; elicit feedback and information from patients about the SDoH-related barriers to health and identify and discuss practical opportunities for the CHC to recognize and address the SDoH.

The staff assessment component may be used to: 1) Gauge and enhance the health center’s understanding of the SDoH; 2) Elicit feedback and information from patients and staff about the SDoH-related barriers to health; and 3) Identify and discuss practical opportunities for the CHC to recognize and address the SDoH.

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)
This report from Food Research & Action Center and Children’s HealthWatch reviews existing and emerging opportunities to document food insecurity screening, assessment, intervention, and billing for each part of a patient visit using discrete codes and language from standardized EHR medical vocabularies.


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)
The Safety Net Medical Home Initiative, launched in 2008 by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute, was a five-year national Patient-Centered Medical Home (PCMH) demonstration to help 65 primary care safety net sites become high-performing medical homes and improve quality, efficiency and patient experience. This implementation guide provides guidance and tools to help practices develop an implementation plan for integrated primary and behavioral health care.  

New Models of Primary Care Workforce and Financing (Agency for Healthcare Research and Quality [AHRQ]. October 2016)
A case study by AHRQ of pharmacy and primary care integration at Fairview Health Services in CT.

Integration of collaborative medication therapy management in a safety net patient-centered medical home (Journal of the American Pharmacists Association. March/April 2011)
This article describes the integration of collaborative of medication therapy management (CMTM) in a community health center that serves people experiencing homelessness. 

Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis (The Commonwealth Fund. October 2015)
This brief analyzes experts’ reviews of evidence about care models designed to improve outcomes and reduce costs for patients with complex needs.

Advancing Quality Family Planning Practices: A Guide for Health Centers (The National Association of Community Health Centers. April 2017)
This resource is designed to support health centers in their efforts to improve access to high quality and comprehensive family planning services. The Guide highlights requirements and considerations for health centers interested in improving their provision of quality family planning and reproductive health services, including becoming a Title X grantee or sub-recipient. The Guide also summarizes various models to collaborate with existing family planning providers in order to leverage the organizations’ respective strengths, ranging from referral relationships to corporate consolidation.  The Office of Population Affairs and the Centers for Disease Control and Prevention within the Department of Health and Human Services funded the Guide development. 

Asthma Community Network – Communities in Action
The Merck Childhood Asthma Network, Inc. (MCAN) and EPA have collected and cataloged implementation and evaluation tools, resources, outcomes and best practices from MCAN’s programs on the Network. This includes the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) training modules, developed and supported by MCAN in conjunction with the RCHN Community Health Foundation, and implementation guide along with materials documenting MCAN’s groundbreaking work in asthma disparities and care management.

Effectiveness of Evidence-Based Asthma Interventions (Pediatrics. May 2017)
Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial enrolling children with moderate to severe asthma in 3 interventions and 3 geographically/capacity-matched control sites located in high-risk, low-income communities in Arizona, Michigan, and Puerto Rico community health centers. Merck Childhood Asthma Network (MCAN) and RCHN Community Health Foundation supported this initiative.

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.


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)
This handbook provides an overview of and rationale for how hospitals can work with patients and family members as advisors at the organizational level, outlines five steps for putting the strategy into place, and includes tools and specific suggestions for how to work with patient and family advisors.

Quitting Smoking is Hard, But You Can Do It! (Charles B. Wang Community Health Center. 2016)
A Chinese/English bi-lingual video on the health risks of smoking and second-hand smoke.


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 Geiger Gibson RCHN Community Health Foundation Research Collaborative is a unique, comprehensive, multi-faceted academic and research initiative focused on community health centers. The Collaborative’s academic home is the Department of Health Policy and Management at Milken Institute School of Public Health, the George Washington University, the only school of public health in the nation’s capital. The Collaborative has produced more than four dozen white papers and special reports, as well as an extensive body of significant peer reviewed literature addressing medical underservice, health disparities and the role of community health centers in America’s safety net.

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)
This report by Dr. Leighton Ku and colleagues in the Department of Health Policy and Management at Milken Institute SPH finds that repeal of the ACA could lead to significant economic disruption and substantial job losses in every state. In 2019 alone, 2.6 million people could lose their jobs. These losses could rise to nearly 3 million positions in health care and other sectors by the year 2021. Research funded by the Commonwealth Fund, the Geiger Gibson RCHN Community Health Foundation Research Collaborative and Milken Institute School of Public Health, George Washington University.

Repealing Federal Health Reform: Economic and Employment Consequences for States (The Commonwealth Fund. January 2017)
Issue brief to determine the state-by-state effect of repeal on employment and economic activity using a multistate economic forecasting model to quantify the effects of the federal spending cuts.

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.

The Quiet War on Medicaid (New York Times. December 25, 2016)
A New York Times op-ed by Gene Sperling, former director of the National Economic Council, urges lawmakers to keep vigilant against the potentially devastating effects of dismantling Medicaid.

America’s concern for the poor is about to be tested (Washington Post. December 26, 2016)
In this Washington Post op-ed, Robert Greenstein discusses the grave threats faced by America’s poor if safety net and domestic programs are cut.

Obamacare Boosted Community Health Centers’ Reach. Now What? (Kaiser Health News. January 9, 2017)

This article summarizes two Health Affairs studies on the impact of Medicaid expansion on community health centers. Medicaid Expansion And Grant Funding Increases Helped Improve Community Health Center Capacity examines the effects of both ACA Medicaid expansion and changes in CHC grant funding levels on the centers’ numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015; it documents increased capacity in expansion states, with more visits overall and more mental health visits/ mental health access. At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care shows that Medicaid expansion was associated with large increases in Medicaid coverage and corresponding declines in uninsurance rates. Medicaid expansion was also associated with improved quality at CHCs on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control.

How Medicaid and Other Public Policies Affect Use of Tobacco Cessation Therapy, United States, 2010–2014 (Preventing Chronic Disease. October 27, 2016)
This article by Dr. Leighton Ku and colleagues assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers.