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Disaster Equity: Preparedness, Response, and Recovery for LGBTQIA+ Patients of Health Centers (2024). Resource Type: Publication. Description: Climate change and natural disasters pose substantial threats to communities, the effects of which are exacerbated by inequalities in vulnerable populations—particularly those with intersectional marginalized identities (e.g., LGBTQIA+ people who are Black, Indigenous, and/or have a disability) and are disproportionately affected by chronic disease. It is vital that health centers pay special attention to the marginalized communities who have been historically forgotten in emergency preparedness and response plans. Social determinants of health such as stigma, discrimination, violence, neighborhood characteristics, transportation, and a lack of recognition of families and relationships in institutional policies dramatically impact the effects of natural disasters on LGBTQIA+ people. This publication will summarize the issues at hand and provide strategies for health centers to promote disaster management equity for LGBTQIA+ patients. More Details...
El Transporte es un Tema de Equidad en la Salud (2024). Resource Type: Publication. Description: The Spanish translation of the Transportation is a Health Equity Issue factsheet investigates how transportation impacts access to care & other social drivers of health, analyzes unmet needs & gaps in laws or policies affecting access to transportation, uncovers the structural factors predisposing marginalized populations to reduced access to transportation and provides recommendations to health centers on addressing patient transportation inequities & barriers. More Details...
Telling Their Stories: Documenting the True Impact of Transportation Barriers on Health (2024). Resource Type: Publication. Description: Transportation impacts every aspect of our daily lives. Accessibility to transportation influences how we meet our basic needs and where we work, live, and receive healthcare. It is why transportation is considered a "mega-determinant" of health. Transportation barriers are one of the most commonly cited reasons for missing a medical appointment. Yet these barriers extend beyond missing an appointment: it can also have a significant impact on health outcomes and quality of life. More Details...
Transportation is a Health Equity Issue Factsheet (2024). Resource Type: Publication. Description: Health Outreach Partners proudly presents a new resource on Transportation and Health Equity. Our newly developed factsheet investigates how transportation impacts access to care and other social determinants of health, analyzes unmet needs & gaps in laws or policies affecting access to transportation, uncovers the structural factors predisposing underserved populations to reduced access to transportation and provides recommendations to health centers on addressing patient transportation inequities and barriers. More Details...
Social Determinants of Health (SDOH) in Oral Health Care: A Step Towards Health Equity for Older Adults (2024). Resource Type: n.a.. Description: Identifying and addressing social determinants (also known as social drivers) of health (SDOH) is a key part of a health center’s approach to providing comprehensive care in their communities. Non-medical factors such as housing, income, transportation, behavioral health, and intimate partner violence can directly contribute to disparities in access and utilization of health care for the whole body, including a person’s mouth. As part of an interprofessional team, dental providers and staff have an opportunity to participate in SDOH screening and documentation to reduce barriers between older patients and oral health services. More Details...
Partnerships and Pathways to Support Healthcare Services in Schools (2024). Resource Type: Archived Webinar. Description: The Partnerships and Pathways to Support Healthcare Services in Schools webinar was designed for health center and health center look-alike staff. The webinar aims to increase the audience's knowledge of and capacity to define how health centers can partner with schools and community organizations to provide healthcare services to school-aged children and adolescents, describe programs to engage parents, and gain awareness of marketing strategies for school-based health centers. More Details...
Enhancing Healthcare Access for Special Populations Through Telehealth and Home Visitation Services: NCHPH Webinar (2023). Resource Type: Archived Webinar. Description: Hosted by the National Nurse-Led Care Consortium and the National Center for Health in Public Housing, this 2-part webinar series discussed promising practices in home visitation and telehealth as ways to support improved access to comprehensive primary care for communities with high levels of disability, and isolation, lack of adequate transportation, and other social drivers of health that contribute to health inequities, particularly residents of public housing. More Details...
Enhancing Healthcare Access for Special Populations Through Telehealth and Home Visitation Services: Part Two (2023). Resource Type: In-Person Training. Description: Hosted by the National Nurse-led Care Consortium and the National Center for Health in Public Housing, this 2-part webinar series discussed promising practices in home visitation and telehealth as ways to support improved access to comprehensive primary care for communities with high levels of disability and isolation, lack of adequate transportation, and other social drivers of health that contribute to health inequities, particularly residents of public housing. More Details...
Enhancing Healthcare Access for Special Populations Through Telehealth and Home Visitation Services: Part One (2023). Resource Type: Online Self-Paced Learning Modules. Description: The first session took place on November 7. We examined how home visitation can be integrated into the provider panel to expand access for aging and disabled patients residing in public housing. More Details...
Community-Centered Approaches to Racial and Social Justice: Change from the Outside In With CCHH (2023). Resource Type: Archived Webinar. Description: This was a two-part webinar series in partnership with the Prevention Institute, with part one exploring the CCHH model and part two diving into operationalizing a community-centered approach. This was our Second session in the series. More Details...
Community-Centered Approaches to Healthcare: Introduction to the CCHH Model (2023). Resource Type: Archived Webinar. Description: This is a two-part webinar series in partnership with the Prevention Institute, with part one exploring the CCHH model and part two diving into operationalizing a community-centered approach. This was our first session in the series. More Details...
Two-Tiered Screening for Patient Social Needs in a Safety-Net Setting: Using Two Pre-Screening Questions to assess patients’ social needs at a Chicago-area FQHC (2022). Resource Type: Template. Description: Erie Family Health Centers, a Chicago-area Federally Qualified Health Center, initiated a two-part social needs screening process with patients in May 2020. A medical assistant asked a single prescreening question about interest in being connected to resources and interested patients received a follow-up call from staff to screen for needs and connect with resources. A second prescreening question was added asking patients their preferred method for receiving resources. The results of this process suggest that a two-tiered screening for social needs is feasible in the safety net setting. More Details...
COVID-19 Safety Measures for Transportation Teams (2021). Resource Type: Archived Webinar. Description: NFCH’s 2-part video series on occupational safety training on COVID-19 for healthcare teams shares tips and strategies to provide support to health care centers as they adapt their health care delivery services. This second video showcases how Sun River Health made adaptions to their transportation department's protocols ensure the safety of their patients and staff while providing care during the pandemic. More Details...
Payment and Delivery Reform: Medicaid in the Time of COVID-19 (2020). Resource Type: Publication. Description: NACHC hosted a 3-part virtual peer learning opportunity on “Medicaid in the Time of COVID-19” as a year-end wrap-up to the 2019 Payment and Delivery Reform Summit. More Details...
Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources: We asked the questions, now what? Updated in December 2018 (2018). Resource Type: Publication. Description: The collection of data related to patients' non-medical needs through use of Social Determinant of Health SDoH assessment tools, can accelerate systemic population health improvement, as well as engage patients in addressing their social non-medical needs such as transportation, shelter, or intimate partner violence services through coordinated access to appropriate services. This case study discusses the process a health center may use to identify and stratify need, and profiles a number of new technologies, including Aunt Bertha, Now Pow, and 211 Community Information Exchange, for connecting patients to appropriate community resources. Download full case study at the bottom of the page. The collection of data related to patients' non-medical needs such as transportation, housing, food security, safety, etc. through use of Social Determinant of Health SDoH assessment tools e.g., NACHC’s PRAPARE, AAFP’s The EveryONE Project, can accelerate systemic population health improvement, as well as engage individual patients in addressing those needs through coordinated access to appropriate services. According to a 2017 American Academy of Family Physicians AAFP survey, 83% of respondents agreed that family physicians should identify and help with social determinants of health. Research from Kaiser Permanente suggests that, of those patients screened for social determinants of health, approximately two-thirds needed some services. PRAPARE pilot data from participating health centers identified housing, utilities, and food as the most frequently identified needs. Unfortunately, 80% of the family physicians surveyed by AAFP responded that they don’t have time to discuss social determinants of health with patients and more than half feel unable to provide their patients with solutions. So, tools are needed to help providers meet these newly identified needs, with existing resources. A number of these tools are profiled in the resource available for free download below. Much like other screenings that are embedded in the regular workflow and used to assess the risk or severity of the patient’s condition, such as the PHQ-9, Social Determinants of Health assessment tools like PRAPARE are designed to operate similarly. Identifying level of risk or need among patients screened for social determinants of health in order to strategize responses is generally done with ‘risk scoring’. Here are two examples: SDoH only: A health center could assign 1 point per social determinant of health identified. Multiple sources: A health center could assign points based on number of chronic conditions, medications, ED visits in the last 12 months, and SDoH, as discussed in this HITEQ population health presentation. Whatever approach is taken, it is important to look at the distribution of risk scores or need levels across the patient population to ensure reasonable proportions identified as high, moderate, and low. Note that Care Management, Competency A in the PCMH 2017 standards is concerned with this. In this resource download below!, we focus on what technology tools exist to address social non-medical needs identified through screening. For those patients with high need, the standard response is likely to be health center-based and intensive. For example, patients with high need may be provided with 1 intensive case management, social workers, and referral coordinators; 2 direct assistance with connecting to resources; 3 follow up with external providers; and 4 regular in-person follow-up visits. This is likely to take up the majority of available staff capacity. However, gathering social determinants of health information may also point to other needs among patients with more moderate needs or in a broader array of areas such as paying utilities or legal services. Given staff capacity and resource limitations, as well as patient preferences, those patients may require another way to be connected with appropriate community resources. It is important that any approaches used allow for tracking and follow-up, as well as provide information about community service capacity. The tools in the case study below including Aunt Bertha, Now Pow, and 211 Community Information Exchange support this process by facilitating connection with community resources and needed follow-up, partially answering the question We collected social determinant of health data, now what do we do? Download the resource below for full case studies and lessons learned from using Aunt Bertha, 211 Community Information Exchange, and other new tools for connecting patients with community resources! More Details...
Transportation Quality Improvement Toolkit (2016). Resource Type: Toolkit. Description: HOP's toolkit titled “Transportation and Health Access: A Quality Improvement Toolkit" is an easy-to-use, practical guide to assist health centers with assessing the scope of the problem and finding solutions to missed medical appointments due to transportation barriers. The toolkit guides the user through the two key phases of the quality improvement process: Needs Assessment and Plan-Do-Study-Act (PDSA) cycle, a continuous quality improvement process. Each section contains an overview of the concepts and sample tools. The tools are designed to be a starting point, and can be customized as needed to align with the specific context and resources of each health center. More Details...
Transportation and Health Access Infobook (2016). Resource Type: Publication. Description: Since 2000, Health Outreach Partners (HOP) has conducted bi-annual national needs assessments of community health centers serving underserved populations. The findings have consistently demonstrated that transportation is a top barrier to health care access. This infobook provides a general introduction to the topic of transportation as a barrier to health care access in the United States. The material is drawn from interviews, case studies, and reviews of existing literature. Although geared towards community health centers, it is relevant to all health care providers. More Details...
Integrating Homeless Service Providers and Clients in Disaster Preparedness, Response, and Recovery: Issue Brief (2014). Resource Type: Publication. Description: This issue brief outlines strategies to integrate people experiencing homelessness into disaster preparedness and response, examines homeless individuals’ and service providers’ awareness and perception of targeted preparedness efforts, and offers recommendations for other communities looking to improve disaster assistance for people experiencing homelessness. More Details...
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.