Table 1.

How the Population Health Assessment Engine Can Be Used to Improve Health

System levelAdjust paymentsMassachusetts and Minnesota adjust Medicaid reimbursements based on SDHs
Contribute to public health surveillanceMacroscope (New York City) and the electronic medical record Support for Public Health (ESP; Massachusetts) use EHRs for public health surveillance
Practice levelOrganize care around hot spotsThe University of Cincinnati's comprehensive care team aims to reduce hospital admissions for children coming from high poverty neighborhoods
Assess patient riskQRISK uses geographic data to calculate risk for cardiovascular disease in the United Kingdom
Connect with community organizationsCommunity 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.