How the Population Health Assessment Engine Can Be Used to Improve Health
| Level | Function | Example |
|---|---|---|
| System level | Adjust payments | Massachusetts and Minnesota adjust Medicaid reimbursements based on SDHs |
| Contribute to public health surveillance | Macroscope (New York City) and the electronic medical record Support for Public Health (ESP; Massachusetts) use EHRs for public health surveillance | |
| Practice level | Organize care around hot spots | The University of Cincinnati's comprehensive care team aims to reduce hospital admissions for children coming from high poverty neighborhoods |
| Assess patient risk | QRISK uses geographic data to calculate risk for cardiovascular disease in the United Kingdom | |
| Connect with community organizations | Community Rx uses diagnosis codes and links patients to relevant community resources |
SDH, social determinants of health; BRFSS, Behavioral Risk Factor Surveillance System; NAMCS, National Ambulatory Medical Care Survey; EHRs, electronic health records; QRISK, cardiovascular disease risk algorithm, ESP, Emergency Service Program.