Addressing health-related social needs is a foundational element of population health management that cuts across the Population of Focus (PoF) work being done throughout our cohort of CHCs. Through PHMI, we aim to support CHCs in addressing the health-related social needs of their populations through the development of systematic social needs screening and referral processes that connect patients to resources available in their communities through Community Supports.
Unmet social needs include unstable housing, food, transportation, and the ability to pay for basic home utilities. These social risks can have a significant negative impact on a person’s overall health and well-being.
To understand CHC progress toward supporting patients' health-related social needs, recently PHMI introduced a new social health measure for bi-annual reporting: the percent of patients in the Population of Focus screened for social risk.
This measure aligns with the PoF work that CHCs are undertaking within the initiative and supports progress toward improving access to social health supports at a population level.
PHMI is working to:
- Identify the resources available in your communities.
- To understand the health-related social needs of your PoF.
- To develop screening workflows that support patient access and staff well-being.
PHMI CHCs can advance this work through coaching support, regional learning sessions with RACs, and will soon launch social health-focused affinity groups, for those who want to dig deeper.