Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data
Characteristics
COORDINATED
Component
Population health oriented
[SYSTEM LEVEL ONLY]
Measure Concept
Identifies and addresses population-level health concerns based on the diversity of the practice and the community
[SYSTEM LEVEL ONLY]
Descriptions
After the practice collects information on social determinants of health, it demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources or other tools to serve the on-going needs of its population.
Routine collection of data on social determinants of health (as required in KM 02) is an important step, but the real benefit to the population comes when the practice uses the information to continuously enhance care systems and community connections to systematically address needs.
Measure or Standard
Standard
Populations
Not specified or not applicable
Level of Measure
Practice/Health Center
Data Source
Evidence of implementation
Measure Identification
NCQA 2017 PCMH standards
Developer/Steward
National Committee for Quality Assurance (NCQA)
Stage of Development/Use
Accreditation