Address Non-medical Factors – Resource Library
- ACO Beneficiary Engagement Toolkit
- Association of a Care Coordination Model with Health Care Costs and Utilization
- Implementing a Hybrid Approach to Select Patients for Care Management: Variations Across Practices
- Robert Wood Johnson Foundation: ACO Evaluation
- The Opportunities and Challenges of the MSSP ACO Program: A Report from the Field
- The Transformation to Value: A Leadership Guide
The following resource(s) may be of value:
Health Value Atlas
Non-Medical Factors
Address Non-Medical Factors
Organizational capabilities related to addressing non-medical factors that impact health
Note: Some organizational capabilities cross over to other domains. There may also be some degree of capability overlap with Health Equity Advancement, Continuous Quality Improvement, and Health Information Technology domains.
Identify intervention candidates
Identify candidates for targeted interventions
Address social needs
Address patient social needs directly and through collaboration with partners
Manage community relationships
Build and manage relationships with non-provider partners
Support external providers
Provide resources and support to external partners
Expand care planning
Consider non-medical needs and barriers in care planning
Collect data
Collect medical and non-medical data
Aggregate data
Aggregate medical and non-medical data into a reliable data set
Analyze data
Extract actionable information from data
Automate data access
Automate timely access to data within and from outside the organization
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