Table 2.

How the Population Health Assessment Engine Can Be Used to Meet Training Milestones

Attainable Family Medicine Milestones Using PHATEExample
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.