GLOSSARY OF TERMS
The following definitions of key terms related to health extension were compiled by the 18 participating states for the 1st National IMPaCT Conference in Oklahoma.
ACADEMIC DETAILING: Face-to-face education, training, and/or support of clinicians or care teams by an ‘expert’ in a particular area, typically pharmacists, physicians, nurses or community health practitioners. The goal of academic detailing is to change the delivery of health services to be consistent with medical evidence, support patient safety, be cost-effective and improve patient care. Academic detailing can be effective in the initial recruitment and education of practices to participate in practice transformation efforts and thus can be used effectively in conjunction with practice facilitation and collaborative learning sessions.
BEST PRACTICES: Specific strategies or methods used by practices and communities to accomplish improvements in care and/or in population health improvement. Identification and dissemination of best practices is a major goal of a health extension program.
CARE TEAMS: Teams within primary care offices that work together to support their patient population, delivering preventive care and education, chronic and complex care, as well as enabling services and support to vulnerable populations. The team might include a medical provider, nurse, care coordinator, health educator, social worker, community health workers, etc.
CARE COORDINATION: The organization of patient care to facilitate the appropriate delivery of health services; activities and interventions that reduce fragmentation and improve the quality of referrals and transitions. Some degree of coordination is indicated for most all patients in the primary care setting. (Institute of Medicine, 2007)
CASE MANAGEMENT: The assignment of patients with complex and/or chronic health problems to an individual responsible for maintaining an increased level of contact with the patient to monitor the ability of the patient to manage his/her condition, and connect the patient with additional providers as well as other resources in the community that will assist the patient in self-management to achieve optimal well-being. Often refers to the more intensive care provided by nurses or other health professionals to high-risk patients. It encompasses both referral and care transitions, as well clinical services such as monitoring, self-management support and medication review and adjustment.
CAPACITY BUILDING: A long-term, continuous, assets-based process of organizational or community development that involves all stakeholders. In health extension, capacity-building is a key strategy and practice for developing the confidence, skills, experience, organizational structures, and resources that individuals, groups, organizations and communities need to improve population health.
CHANGE STRATEGIES: Organizational and individual strategies that are directed toward helping practices transform their infrastructure and workflow toward improved quality, reduced cost and improved patient experience of care.
CLINICAL DECISION SUPPORT: Integration and utilization of tools, processes, data, clinical guidelines, reminders and alerts, into the primary care delivery design to inform care and decisions point-of-service.
COLLABORATIVE LEARNING SESSIONS: Learning sessions are meetings of practices or care teams as ‘collaboratives’ working on shared goals that include both education and sharing among the practices. While standalone collaboratives have been variably successful, collaborative learning sessions as a health extension strategy appear to improve the effectiveness of practice facilitation interventions. These learning groups are pulled together to share lessons learned, review their performance data, participate in discussions around webinars and other training, hear speakers, or just to brainstorm a topic common to all of them. See also Learning Collaboratives.
COMMUNITY CENTERED HEALTH HOMES (CCHH): Community Centered Health Homes integrate clinical service delivery with community prevention in order to reduce demand for resources and services; improve health, safety, and equity outcomes; and provide medical providers with skills and strategies to change the social circumstances that shape the health of their patients A CCHH approach enables primary care systems to promote community health as they deliver high quality medical services to individuals. The CCHH model is highly responsive to the opportunity to innovate stimulated by the Affordable Care Act. It adds depth to the community-oriented primary care model by adding focus on active involvement in community advocacy and systems change, linking community prevention to treatment outcomes. (Prevention Institute, 2011). Supporting primary care practices to develop into CCHHs can be a focus of health extension efforts where a practice or community health center sets an aim at population health improvement.
COMMUNITY HEALTH ASSESSMENT: Ideally, a locally-driven process to identify the health status of the community. To demonstrate ‘community benefit’, the Affordable Care Act requires not-for-profit hospitals to conduct community needs assessments at least once every three years and to adopt an implementation strategy (i.e. a community health improvement plan) to address the identified needs.
COMMUNITY HEALTH IMPACT ASSESSMENT/MENTAL HEALTH IMPACT ASSESSMENT: Health Impact Assessment (HIA) is a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (European Center for Health Policy 1999). HIAs are intended to produce a set of evidence-based recommendations to inform decision-making (Taylor & Quigley 2002), and aim to maximize the positive health impacts and minimize the negative health impacts of proposed policies, programs or projects. Mental Health Impact Assessments (MHIAs) measure how public policies can affect the mental health and well-being of individuals and communities. As ‘health homes’, primary care practices can be essential participants/stakeholders in HIAs and MHIAs. Incorporation of HIA/MHIA findings may be a focus of health extension efforts to support transformation of practices into community-centered health homes. See also Community-Centered Health Homes.
COMMUNITY HEALTH IMPROVEMENT (CHI): A community’s comprehensive approach to maintaining and improving health: assessing its health needs, determining its resources and assets for promoting health, developing and implementing a strategy for action, and establishing where responsibility should lie for specific results (National Academies of Practice 2013). Accessible, effective and engaged primary care systems are essential components of CHI.
COMMUNITY HEALTH TEAMS: Integrated groups (may include FQHCs, hospitals, long-term care facilities, public halth systems, managed care organizations, etc) that effectively manage high-need patients, often with complex illnesses, across providers, settings and systems. The community health team innovations include an array of promising practices for improving access and outcomes, reducing costs, and enabling resource-strained practices to provide more comprehensive services (Commonwealth Fund, 2013).
COMMUNITY HEALTH WORKER (CHW): CHWs are frontline health workers who are trusted members of the communities they serve. CHWs may provide a variety of educational, preventive, chronic care, and enabling services. They can improve access to care through outreach and by building the cultural and community competence of care teams and organizations. They support and motivate patient engagement and activation, improve care coordination and utilization, and enhance trust and customer service. Integration of CHWs into care teams and deployment into communities is a key strategy for transforming primary care.
COMMUNITY-ORIENTED PRIMARY CARE: Primary care practices and community health centers that are oriented and responsive to the needs of underserved and isolated communities.
COMMUNITY RESOURCES: Services and programs that are available to members of a community to help them engage in self-care, develop self-reliance, and maintain their human rights and wellbeing.
COMMUNITIES OF SOLUTION: Practice learning communities can be extended to include community agencies, patient advisory groups, public health resources, and others from the community interested in health, forming communities of solution that can catalyze change and improvement based on community need and priorities. See also Collaborative Learning Sessions and Learning Collaboratives/Learning Communities.
CRITICAL HEALTH LITERACY: An individual’s understanding of the social determinates of health, combined with the skills to take action at both the individual and the community level (Mogford, Gould, and DeVoght, 2011).
DIMENSIONS OF QUALITY: Health care that is safe, effective, timely, patient-centered, efficient and equitable (Institutes of Medicine, 2001).
HEALTH EQUITY: Attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities (CDC, Healthy People 2020). Health equity is a central aim and core value of many health extension programs.
HEALTH INFORMATION EXCHANGE (HIE): ‘Health information exchange’ encompasses two related concepts: the electronic sharing of health-related information among organizations; and also refers to an organization that provides services to enable the electronic sharing of health-related information.
HEALTH INSURANCE EXCHANGE (HIX) or “MARKETPLACE”:Established by the Affordable Care Act, the Health Insurance Marketplace is a set of government-regulated and standardized health care plans in the U.S. from which individuals may purchase health insurance eligible for federal subsidies.
HEALTH LITERACY: Health literacy is the degree to which individuals have the capacity to obtain, process, communicate and understand basic health information and services needed to make appropriate health decisions (Ratzan & Parker 2000). Health literacy gaps occur when the tasks required of consumers by health systems exceed people’s capacity to perform those tasks. Poor health outcomes as a result of health literacy gaps include lower self-management capacity, decreased ability to share in clinical decision-making, lower adherence to therapy, higher rates of hospitalization, emergency department utilization, lower self-reported health status, and higher health care costs. Encouraging and assisting practices to identify and close health literacy gaps is a critical activity of health extension.
HOT SPOTTING: Using data to identify top diagnoses, utilization patterns, and utilization anomalies (along with geo-mapping to derive where they emanate from) so that targeted, intensive intervention programs can be instituted.
LEARNING COLLABORATIVE/LEARNING COMMUNITY: An approach to improving care, efficiencies and patient-centeredness, in which care teams and staff work together redesign their systems to improve performance. Applied to the aims of health extension, new collaboratives can be formed (or existing can be leveraged) to share challenges, experiences and best practices around transformation. Learning communities can also provide the basis for a practice-based research network (PBRN) of practices interested in supporting research to fill the gaps in knowledge and practice. See also Collaborative Learning Session.
MEANINGFUL USE (MU): Specific objectives that practices must achieve to quality for Centers for Medicare & Medicaid (CMS) incentive programs. Meaningful use entails the use of certified electronic health record (EHR) technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination, and population and public health; and, maintain privacy and security of patient health information. MU measures are integrated as ‘must-pass’ elements into the NCQA-PCMH (National Committee for Quality Assurance) framework of standards, and thus are a focus of primary care transformation efforts.
OFFLOADING: In states with primary care provider shortages (increasing as insurance coverage expands), one strategy for practices to accomplish certain types of care delivery is to ‘offload’ care components (i.e. flu shots, preventive services, behavioral counseling) from primary care to community partners, such as public health offices, community pharmacists, community paramedics, etc.
PATIENT ACTIVATION: Utilizing motivational approaches to cultivate a patient’s self-efficacy in managing their health and health care.
PATIENT CENTERED MEDICAL HOME (PCMH): Researchers involved in the National Demonstration project define PCMH concisely as ‘a team of people committed to improving the health and healing of individuals in a community’. Transforming a medical practice to a PCMH focuses on the fundamental tenets of primary care (e.g. accessibility, comprehensiveness, coordination and integration, relationships), new ways of organizing care (e.g., electronic visits and team-based care), developing internal capabilities (e.g. leadership and management structure and capacities), and making reimbursement changes (e.g. blended payments and care management fees) (Strange, Nutting & Miller et al 2010). Most broadly, PCMH can be defined as a specific change package toward accomplishing improved primary care, as a policy-directed method for improving support for primary care practices, or as a set of requirements practices have to accomplish.
PATIENT ENGAGEMENT: A set of knowledge, skills, and attitudes that patients, clinicians and health systems require in order to involve the patient in the care delivery process and health decision-making (Bernabeo & Holmboe, 2012).
PATIENT REGISTRY: An information system (complied manually from charts or electronically from an EHR) used to track and manage preventive and chronic care in individual patients, as well as across a practice’s patient population. Registry data and analysis are essential for care teams to track and measure their performance, plan improvements and demonstrate outcomes.
POPULATION HEALTH: Population health is the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. The health outcomes of such groups are of relevance to policy makers in both the public and private sectors (Kindig & Stoddart, 1990, 2003)
PRACTICE BASED RESEARCH NETWORK (PBRN):Groups of primary care clinicians and practices working together to answer community-based health care questions and translate research findings into practice (AHRQ).
PRACTICE COACHING/FACILITATION/SUPPORT: A supportive service provided to a primary care practice by a trained individual or team, using a range of carefully-tailored clinical and organizational assessments and improvement approaches to build the internal capacity of the practice to improve outcomes. May include interventions leading to incremental quality improvement, as well as transformative change. See also Practice Transformation.
PRACTICE FACILITATOR/PRACTICE COACH: An individual (internal or external to the practice) who has been trained to assist practices in improving their care of patients and the infrastructure of their practice or organization. A content area expert who can translate the standards of PCMH into the reality of primary care practices in a manner that is non-threatening and supportive of the efforts being undertaken by the practice.
PRACTICE TRANSFORMATION: Continuous development of the capacity of primary care clinicians, teams and systems to learn, adapt and endure the disruption of complex change to improve health care and health.
PRIMARY CARE PROVIDER (PCP): A health care practitioner (physician, nurse practitioner, physician assistant) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine. A PCP provides first contact, comprehensive, ‘whole person’ and continuing care for a defined population of patients across the lifecourse, including prevention, education, diagnosis and medical treatment.
RURAL HEALTH WORKFORCE PIPELINE DEVELOPMENT: Initiatives and programs aimed at cultivating the interest, training, recruitment and retention of rural residents in health professions. Aims and strategies for pipeline development are informed by a body of evidence demonstrating rural residents are most like to return to rural practice, thus addressing critical health professions shortages and disparities experienced by rural communities. Develop of rural health workforce pipeline may be a key aim of health extension programs.
SHARED RESOURCES: Resources that can be shared by individuals and organizations to help achieve program objectives. Smaller primary care practices trying to achieve PCMH or other enhanced primary care models often lack the necessary staff resources to do so. Sharing resources such as care managers, clinical pharmacists, social workers, behavioral health specialists, community health workers, or health extension agents with other practices in a community can become an efficient method for smaller practices to implement these services for their patients and communities. Assisting practices to develop shared resources can be an important component of health extension services.
SOCIAL DETERMINANTS OF HEALTH: The conditions in which people are born, grow, live, work and age, including the health system. The social determinates of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries (World Health Organization, 2005). See also Health Equity.
TRIPLE AIM: The tripartite goals for improving the U.S. health system that inform health extension as practiced in primary care environments. This includes better care for individuals (as delineated in the Institute of Medicine’s ‘six dimensions of quality’); better health for populations by addressing the upstream determinates of health and disease; and better value in health care, by reducing waste and inefficiencies. Implicit in the Triple Aim is the commitment to universality, resulting in health equity (Berwick, 2008).