A range of resources and tools are needed by organizations working to develop more effective population health management capacity and improve patient experience and outcomes. Reports, applications and guides related to practice transformation, capacity building and population health include:

Social Determinants of Health Needs Assessment Survey (Colorado Community Health Network. 2015)

This needs assessment tool, part of the broader “Patient Engagement: A toolkit from the Colorado Community Health Network,” can be used to identify the barriers related to social determinants of health (SDoH). Its objectives are 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.

PRAPARE – Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (National Association of Community Health Centers (NACHC), the Association of Asian Pacific Community Health Organizations (AAPCHO), the Oregon Primary Care Association (OPCA), and the Institute for Alternative Futures (IAF). 2014)

The PRAPARE tool was created as part of a pilot to implement, test, and promote a national standardized patient risk assessment protocol to assess and address patients’ social determinants of health (SDoH). Four Implementation Teams across the country, each with at least one health center and one health center network, participated in a Learning Community (LC) to pilot-test PRAPARE in 2015.

The PRAPARE pilot was funded by the Kresge Foundation, Kaiser Community Benefit, and Blue Shield of California Foundation. Additional resources and information about PRAPARE is available at http://www.healthcarecommunities.org/ResourceCenter.aspx andhttp://enablingservices.aapcho.org/.

INTERMED Method (INTERMED Foundation. 2006)

INTERMED is a decision support system that assesses multiple health risks and health needs by means of a semi-structured interview based on the biopsychosocial model. The primary goal of the IM method is to improve the flow of information and the communication with complex patients and among their health providers. INTERMED provides a rapid, comprehensive, assessment of an individual presenting for medical care that supports individual case planning and management and allows for the development of an empirical database on complex health care needs to support planning, evaluation, and research activities.

NYS Care Coordinator Role Definition (New York State Department of Health. 2015)

This document provides definitions of the Care Coordinator role as they are used across different providers in New York State.

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, this National Quality Forum, using a multi-stakeholder, collaborative process is developing a common framework for communities intended to offer practical guidance for improving population health. The Action Guide is a handbook to be used by those who want to improve health across a population, whether locally, regionally, state-wide, or nationally. It suggests ten useful steps toward 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)

The manual aims to support people who work in community health coalitions by providing insight about the nature and development of these coalitions. Information for the report came from a multiyear assessment and formal evaluation of RWJF-funded statewide tobacco control coalitions. The manual is also intended to get people thinking about why they have chosen to use coalitions in their work, the structures and process they are using, and assumptions in building coalitions.


Collaboration is a key aspect of population health management, and effective tools are needed both for documenting and managing partnership implementations and evaluating them. PARTNER (Program to Analyze, Record, and Track Networks to Enhance Relationships) is a low-cost social network analysis application that incorporates both a survey and analysis tool for collaboration monitoring. The tool is sponsored by the Robert Wood Johnson Foundation and designed for use by collaboratives/coalitions to demonstrate how members are connected, how resources are leveraged and exchanged, the levels of trust, and to link outcomes to the process of collaboration.