Population Health Mapping Tool Addresses Social Determinants of Health

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True population health involves measuring and examining patients in a community context, but this can be difficult to do when simply comparing patient data. A recent article in the Journal of the American Board of Family Medicine, Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE), describes what PHATE can do to support practices.

Addressing social determinants of health is essential to reducing pervasive health disparities, yet physicians still struggle with methods to identify patients’ needs and how to address those needs.

True population health involves measuring and examining patients in a community context, but this can be difficult to do when simply comparing patient data. If clinicians can attach geography to patient data, then they can better associate those patients with the community in which they live. PHATE does just that and more. PHATE is a population health tool commissioned by the American Board of Family Medicine and developed in collaboration with the Center for Applied Research and Engagement Systems (CARES) at the University of Missouri. A recent article in the Journal of the American Board of Family Medicine, Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE), describes what PHATE can do to support practices.

With PHATE, clinicians can gain a fuller understanding of their patient population in the context of their community. PHATE utilizes patient data from the PRIME Registry to assign a Community Vital Sign—a Social Deprivation Index score—to an individual patient based on Census Tract characteristics. Clinicians can also use PHATE to identify clusters of disease and poor outcomes in the community context with the Community Hotspots feature. PHATE is also useful in helping identify and address social needs—whether at the individual patient level, or at the community level. The PHATE dashboard provides links to local resources based on the selected census tract, or for a specified zip code. Eventually, PHATE is anticipated to help practices get paid adequately to assess and address patients’ social needs. PHATE is a clinical information tool that can be used to reduce clinical burden, integrate and address social determinants of health, and support and educate the next generation of physicians.

“Whether you’re in an integrated network or small practice, we’re all being asked to deliver ‘population health’ in primary care these days. And that’s something that is easy to say, but really hard to do in primary care practice without the right tools,” says Dr. Winston Liaw, Chair of Health Systems and Population Health Sciences at the University of Houston College of Medicine.

The full article, Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE), can be found by clicking here: https://www.jabfm.org/content/33/3/463

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Jane Ireland

Jane Ireland
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