Not owning a vehicle in New York City has negligible impact on a person’s health. Not owning one in a rural area — or even a booming metropolis like Nashville that lacks a diversified public transportation system — can be life-threatening. This tale of two cities suggests that transportation, perhaps more than any other social determinant of health, illustrates the link between ZIP code, disparities and health outcomes. The importance of transportation Missing medical appointments due to lack of transportation is a stark example of how SDOH can directly impact health outcomes. The ability to get where and when you need to is also connected to other social determinants of health domains such as finance, food and housing. However, one study found that transportation is found in fewer SDOH assessment tools (66%) than any other metric besides social and community context (61%) and physical activity (33%). Addressing transportation inequality begins with knowing how it impacts populations ...

The National Committee for Quality Assurance (NCQA) releases updates annually to the Patient-Centered Medical Home (PCMH) Standards and Guidelines. Any primary care practice, whether first transforming to achieve PCMH recognition, or a practice seeking to maintain recognition, must implement and demonstrate the core criteria of the PCMH standards and guidelines. NCQA has added numerous elective criteria for practices to pursue to ensure they have an adequate amount of credits to achieve recognition between the mandatory core and elective criteria available. Practices should visit the NCQA website for the latest version (v8) of the standards and guidelines , released on July 1, 2022. Health equity An update made this year is to best align with the Health Equity Accreditation/Plus program offered by NCQA. Also, in response to lessons learned from the COVID-19 pandemic, PCMHs should be positioned to understand what vulnerabilities and social determinants may impact their patients...

Why is healthcare so confusing? Navigating its complexity is the last thing a patient needs when their health is on the line. Yet, this confusion happens every day — even to career healthcare professionals who understand how the system works. Many startups have been launched to "fix healthcare" due to a founder's personal negative experience. The Health Resources and Services Administration defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.” Without healthcare literacy, navigating the complexities of the healthcare system becomes impossible. It is the foundation of patient self-advocacy. Addressing health literacy goes to the heart of literacy itself. It has as much to do with how information is presented as how it is understood. "Health literacy represents a lot of opportunity on the healthcare industry side. We can do a lot better than...

Updated essential CHNA guide available here.  For hospitals, the question arises every three years: How can we conduct a Community Health Needs Assessment that delivers more insight for better population health with less burden? Allocating appropriate resources and finding the bandwidth and expertise to execute a fully compliant CHNA is a challenge — particularly for first-time submissions or during strategic transitions. As hospitals prepare for their next CHNA, the following information can guide strategies to maximize assessment tools, metrics and analyses — all for better interventions and outcomes. And, if you want to know all the components, our essential Community Health Needs Assessment (CHNA) guide provides a comprehensive overview of the CHNA, including its purpose, requirements, data analysis and examples.  Simplify a complex process without burdening staff. It’s difficult for hospitals to achieve efficiencies of scale for a process like CHNA that only occurs every...

It’s 5 p.m. on a Tuesday. You’re exhausted and still need to pick something up for dinner. The nearest grocery store is 15 miles away, and the only thing closer is a convenience store with higher prices and fewer healthy options. This is what it can be like to live in a food desert  — one of several contributing factors of food insecurity. Food insecurity and limited or uncertain access to adequate food impacts millions of Americans each year. And the pandemic only compounded access and affordability issues that drive food insecurity like irregular income, unemployment and disability. Add to this heredity’s influence, race and ethnicity and you have a very complex picture of food-related health issues in 21-century America. While most social determinants of health lay outside of healthcare’s circle of influence, they create conditions that erupt inside its circle of treatment. In most cases, the healthcare industry faces acute to downstream effects in the form of imprope...

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly. To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made. Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate: Nuances classifying care delivered by provider team members: It’s difficult to distinguish ...

The Kidney Care Choices (KCC) Model is welcoming a new cohort of participants in January 2023. KCC is a voluntary model for nephrology practices, nephrology professionals and kidney contracting entities.  KCC provides financial incentives to help providers improve the quality and reduce the cost of care for patients with late-stage chronic kidney disease and end-stage renal disease. The program’s main goals are to delay the progression of CKD to ESRD, effectively manage the transition onto dialysis, support beneficiaries through the transplant process and keep them healthy post-transplant. In addition to announcing Cohort 2, CMS shared more information on the incentive structure and quality measures current and future participants must understand. Successful participation in the program will drive: reduction in total cost of care; comprehensive and coordinated care delivery; and improved access to care. Participants can achieve these benefits through three strate...