How the Population Health Assessment Engine Can Be Used to Meet Training Milestones
| Attainable Family Medicine Milestones Using PHATE | Example |
|---|---|
| Identifies specific community characteristics that impact specific patients' health. | PHATE can be used as a primary screening tool to identify patients at risk for adverse health outcomes; once identified, patients can be further screened to determine the effect their SDH have on their health outcomes. For example, knowing that a given community has a high crime rate can prompt a physician to ask patients about the level of safety they experience in their homes. |
| Collaborates with the participants necessary to address important health problems for both individuals and communities. | PHATE helps identify community partners like food banks, housing and transportation services, and education resources. |
| Mobilizes team members and links patients with community resources to achieve health promotion and disease prevention. | Community health workers and case managers can connect patients with unmet social needs with community resources through Aunt Bertha. |
| Lists ways in which community characteristics and resources affect the health of patients and communities. | Clinicians can look at maps of their service areas, which help them have a visual representation of the neighborhood deprivation within the local community. |
| Recognizes inefficiencies, inequities, variation, and quality gaps in health care delivery. | The hot spotting tool displays, geospatially, clusters of patients with gaps in quality or poor disease control. |
| Integrates practice and community data to improve population health. | Once clusters are identified, PHATE helps clinicians identify risk factors that can account for or address hot spots. |
PHATE, Population Health Assessment Engine; SDH, social determinants of health.